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  5. Autonomy in the Older Adult Pre-Test
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Exit Survey
 
 
What is your gender?
 
Male
 
Female
 
 
 
What is your marital status?
 
Single (Never married)
 
Married
 
Domestic partnership
 
Widowed
 
Divorced
 
Separated
 
Don’t know
 
 
 
What is your age?
 
Younger than 18
 
18 - 24
 
25 - 34
 
35 - 44
 
45 - 54
 
55 - 64
 
65 or older
 
Prefer not to answer
 
 
 
What is the highest level of education you have achieved?
 
Less than high school degree
 
High school degree or equivalent (e.g. GED)
 
Some college but no degree
 
Associate degree (e.g. AA, AS)
 
Bachelor's degree (e.g. BA, AB, BS)
 
Master's degree (e.g. MA, MS, MBA)
 
Professional degree (e.g. MD, DDS, JD)
 
Doctorate degree (e.g. PhD)
 
 
 
How many children do you have?
 
no children
 
1 child
 
2 children
 
3 children
 
more than 4 children
 
 
 
What year of school are you in?
 
Freshman
 
Sophomore
 
Junior
 
Senior
 
Graduate student
 
 
How would you rank your current understanding of the following topics regarding elderly patient autonomy:
Very Good Good Poor Very Poor
Food
Driving
Intimacy
 
 
 
Please describe level of interaction with elderly adults:
   
 
 
 
What is your date of birth?