Caregiver Survey
Please answer all questions with an asterisk (*).
1. Caregiver Survey
  Please answer the following questions as honestly as possible. All information will be kept strictly confidential. Thank you for your participation.
 
1. Age *
 
 
 
2. Age of patient *
 
 
 
3. Gender *
      
 
 
 
4. Do you have any children at home? *
      
 
 
 
5. Relationship to patient: *
      
 
 
 
6. Do the caregiver and patient live in the same house? (If not, please indicate the frequency of contact between patient and caregiver in days per week and hours per day) *
 
 
 
7. Approximate date (month and year) of onset of patient’s disease *
 
 
 
8. Approximate date (month and year) of diagnosis of patient’s disease *
 
 
 
9. Does the patient have any other hired helper at home besides for you? (If yes, how many days per week and hours per day) *
 
 
 
10. How difficult do you find your caregiving responsibilities *
      
 
 
 
11. How well do you believe you handle your caregiving responsibilities? *
      
 
 
 
12. Do you believe that learning to prevent problems or respond differently to your ill relative can help reduce your stress? *
      
 
 
 
 
 

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