Baseline Questionnaire - GeroNet

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Perceived Efficacy in Physician-Patient Interactions (PEPPI)responses for all Q'sC O N F I D E N C EL E V E L1..........2.........3..........4.........5Not at allConfidentVeryConfidento3base15.fm
Page 1 and 2: O3base16.fmBASELINE QUESTIONNAIRE T
Page 3 and 4: 5. Does your health now limit you i
Page 5 and 6: 17. During the past 4 weeks did you
Page 7 and 8: 25. During the past 4 weeks, how mu
Page 9 and 10: 33. I expect my health to get worse
Page 11 and 12: ID#________IAPATIENT SATISFACTION Q
Page 13 and 14: 9. All things considered, the medic
Page 15 and 16: 19. I am dissatisfied with some thi
Page 17 and 18: ID#__________IAQUALITY OF WELL-BEIN
Page 19 and 20: 11. Trouble talking (e.g. lisp, stu
Page 21 and 22: 1. Did you drive or ride in a car y
Page 23 and 24: F. DAILY ACTIVITIES:1. Did you use
Page 25 and 26: ID#___________NIA BATTERY ADMINSTRA
Page 27 and 28: IAID#__________NIA BATTERY ADMINSTR
Page 29: Health Status Questionnaire (SF-36)

Baseline Questionnaire - GeroNet

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