CAREGIVER WELLNESS QUESTIONNAIRE
What state are you from?
1. What is your gender?
2. What is your age?
3. What is your relationship to the person you care for?
4. Do you have someone you could talk to if you needed emotional support or had a difficult decision to make?
5. Do you talk to close friends or relatives (in person or on the phone) at least once a week?
6. Do you belong to any community, volunteer groups or organizations?
7. Do you have any chronic illnesses (such as: diabetes, arthritis, high blood pressure, etc.)?
8. Have you ever been diagnosed with depression?
9. In the last month, has the time you have devoted to caregiving restricted or negatively affected:
a. Your caring for yourself
b. Your caring for others
c. Your sleeping habits
d. Your physical health
e. Your mental health
f. Your hobbies/recreation
g. Going to work
h. Maintaining friendships
10. In the last month, how often have you been frightened by the illness of the person you are caring for?
11. In the last month, how often have you felt helpless by the illness of the person you are caring for?
12. Being in severe pain or discomfort?
13. Not being able to eat or swallow/choking?
14. Has he/she been vomiting?
15. Has there been any dehydration?
16. Has he/she had any insomnia?
17. Has he/she been falling, collapsing or passing out?
18. Has he/she been confused or delirious?
19. Have you felt that the person you are caring for has been through enough?
20. Has a doctor or healthcare professional told you that the illness of the person you are caring for is not curable?
20a. Have you been told that the person you are caring for will probably not have longer than 6 months?
21. Do you suspect that the person you are caring for has a limited life expectancy?
22. Has anyone talked to you about home/inpatient hospice care?
22a. Would you like more information about hospice services?
23. Is the patient that you are caring for receiving home/inpatient hospice?
24. Would you be interested in possibly being contacted as part of our future research being conducted by Yale School of Public Health and the John D. Thompson Hospice Institute for Training, Education and Research? If so, please enter you email address:
Research has identified 13 risk factors for major depression and poorer
quality of life for caregivers of seriously ill loved ones. Your responses to
this survey will tell you how many of these risk factors you have.
Thank you and Best Wishes
The John D. Thompson Hospice Institute for Education, Training and Research, Inc.100 Double Beach RoadBranford, CT 06405