LifestyleQuestionnaire

1
Patient Name
2
Care Partner Name
3
Care Partner Phone
Area Code
Phone Number
4
Care Partner Email
example@example.com
5
What are the main goals for your participation in this program? Examples: allowing them to remain at home, providing relief for their caregiver, keeping them safe, etc.
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6
What name or nickname does this person prefer to be called?
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7
Who does this person live with? For example, do they live with a spouse, children, other family members, etc.?
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8
Are there any pets currently or previously living in the home or with family members?
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9
What is their spouse's name, nickname, are they still alive, how did they meet, etc.?
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What are the names, ages, current locations, occupations, and relationships of their children?
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What are the names, ages, locations, and relationships of their siblings? Any nicknames?
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12
What are their parents' names, occupations, places of origin, and relationships?
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13
What are their parents' names, occupations, places of origin, and relationships?
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14
What are their parents' names, occupations, places of origin, and relationships?
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15
Who were their childhood friends' names and nicknames?
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16
Are there any topics that upset them that should be avoided?
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17
Are there any weapons, like guns, stored in the home? If so, are they unloaded and locked away securely?
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18
Where did they grow up? What cities or towns?
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19
Did they have any lifelong habits or routines? For example, reading the paper every morning.
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20
Did they have any lifelong habits or routines? For example, reading the paper every morning.
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21
What extracurricular activities did they do in high school or college, like sports, clubs, cheerleading, etc?
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22
What are their favorite foods or treats?
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23
What do they like to drink?
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24
What are their favorite snacks?
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25
What is their typical daily breakfast, lunch, dinner, and snacks?
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26
What were their favorite restaurants? Can they still go out to eat?
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27
Where did they travel, both within the country and internationally? Where was their honeymoon?
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28
Where did they like to vacation?
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29
What major influences did they have, like war, college, work, or famous people?
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30
What was their occupation and work history, including jobs as a teen or young adult?
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31
What is their religion and how active are they? Is prayer important?
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32
What were their hobbies and interests growing up and as an adult?
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33
What topics do they love talking about?
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34
Were they part of any clubs, organizations, or memberships?
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35
What were their favorite books, magazines, or other reading materials?
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36
Did they have favorite or special holidays?
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37
What activities were they very proud of or excelled at, like sports, singing, dancing?
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38
Did they have any favorite or peculiar sayings?
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39
What activities have you tried with them that they liked or disliked?
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