Caregiver Stress Pre-Survey

3. What is the gender of the person you take care of?

• Female
• Male

4. Age of the client?

• Between 18 to 40 years
• over +40 years
• Under -18 years Please enter an 'other' value for this selection. * This question is required.

5. How long have you been providing care?

• I am new caregiver
• In the middle (2-5 years)
• Long term (more than 5 years )

6. Describe his/her medical situation.

• mental
• physical
• other (describe)

7. How would you rate your stress level? (min (1)-----(10)Max)?

1	2	3	4	5	6	7	8	9	10
1	2	3	4	5	6	7	8	9	10

8. What measure do you take to reduce your stress level?

• Exercise
• Hobbies
• Talk to friends
• Nothing

9. Is that effective in reducing your stress level?

• Yes
• No
• Sometimes

10. How many hours per day do you spend caring for a person you take care of?

• high 16 to 24 hours
• middle 8 to 16 hours
• few less than 8 hours
• N/A no answer

11. How much time do you spend caring for yourself daily?

• high 16 to 24 hours
• middle 8 to 16 hours
• few less than 8 hours
• N/A no answer

12. Have you been able to access respite care (having someone come in to care for your client to give you a rest)? If not, why? If you have, did your insurance pay for it?

• Yes
• No
• I'm Not Interested

13. What would you like to get out of a support group? In other words, how is a support group going to benefit you and change your life?

• Get out of the stress (vent).
• I do not want the support group, will not help.
• Share and receive encouragement & resources from other caregivers.
• help me hoe to deal with my love's one and cope with with family challenge.

14. What is the most challenging or stressful aspect of the care that you provide?

• The care itself is the most stressful part.
• The care receiver (the person who need care), whether their behavior, bad relationship with them, I always worry about them when I am away.
• I need more time for myself and the other family member, I feel I need more help, I'm not patient.
• nothing is challenge, I am satisfied with my situation.

15. Does thinking about the future for your loved one cause me additional stress?

• Yes
• No
• Sometimes

16. Does thinking about your future cause me additional stress?

• Yes
• No
• Sometimes