Caregiver Health Survey

How long have you been a caregiver?

Does the person you care for have a chronic or life-threatening medical condition?

YesNo

How many hours per week would you report that you spend on caregiving tasks?

Less than 10 hours10-20 Hours21-40 HoursMore than 40 Hours

Since becoming a caregiver, have you been diagnosed with any chronic health conditions? (select all that apply)

Did any of these conditions develop or worsen after you became a caregiver?

YesNoNot sureI have not experienced any of the conditions in the question above

From a ranking of critical alert to fair, how would you describe your current overall health?

Critical Alert (high risk)Warning (moderate-high risk)Fair (moderate risk)Stable (good health)

How often do caregiving responsibilities interfere with your ability to manage your own health (appointments, rest, treatment, exercise, proper nutrition etc.)

How many hours of sleep do you typically get per night?

Do you feel you have adequate support to sustain your caregiving role without harming your own health?

YesSomewhatNo

In one sentence, how has caregiving impacted your physical health?

Prior to becoming a caregiver, how would you describe your overall health?

Since becoming a caregiver, have you experienced any of the following physical symptoms regularly? (select all that apply)

Do you believe stress related to caregiving has contributed to changes in your physical health?

Yes, significantlyYes, somewhatNoNot sure

Have you delayed or avoided medical care for yourself because of caregiving responsibilities?

On average, how would you rate your stress level related to caregiving?

If healthcare providers better understood the impact on your health, what would you want them to know?