The John D. Thompson Hospice Institute for Education, Training and Research, Inc.
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CAREGIVER WELLNESS QUESTIONNAIRE

What state are you from?

1. What is your gender?

Female
Male

2. What is your age?

3. What is your relationship to the person you care for?

Spouse
Child
Other Relationship

4. Do you have someone you could talk to if you needed emotional support or had a difficult decision to make?

Yes
No

5. Do you talk to close friends or relatives (in person or on the phone) at least once a week?

Yes
No

6. Do you belong to any community, volunteer groups or organizations?

Yes
No

7. Do you have any chronic illnesses (such as: diabetes, arthritis, high blood pressure, etc.)?

Yes
No

8. Have you ever been diagnosed with depression?

Yes
No

9. In the last month, has the time you have devoted to caregiving restricted or negatively affected:

a. Your caring for yourself

 Yes      No

b. Your caring for others

Yes      No

c. Your sleeping habits

Yes      No

d. Your physical health

Yes      No

e. Your mental health

Yes      No

f. Your hobbies/recreation

Yes      No

g. Going to work

Yes      No

h. Maintaining friendships

Yes      No

10. In the last month, how often have you been frightened by the illness of the person you are caring for?

Never
Once or twice
Every week or more

11. In the last month, how often have you felt helpless by the illness of the person you are caring for?

Never
Once or twice
Every week or more


In the last month, have you witnessed the person you are caring for experiencing any of the following:

12. Being in severe pain or discomfort?

Never
Once or twice
Every week or more

13. Not being able to eat or swallow/choking?

Never
Once or twice
Every week or more

14. Has he/she been vomiting?

Never
Once or twice
Every week or more

15. Has there been any dehydration?

Never
Once or twice
Every week or more

16. Has he/she had any insomnia?

Never
Once or twice
Every week or more

17. Has he/she been falling, collapsing or passing out?

Never
Once or twice
Every week or more

18. Has he/she been confused or delirious?

Never
Once or twice
Every week or more

19. Have you felt that the person you are caring for has been through enough?

Never
Once or twice
Every week or more

20. Has a doctor or healthcare professional told you that the illness of the person you are caring for is not curable?

Yes
No

20a. Have you been told that the person you are caring for will probably not have longer than 6 months?

Yes
No

21. Do you suspect that the person you are caring for has a limited life expectancy?

Yes
No

22. Has anyone talked to you about home/inpatient hospice care?

Yes
No

22a. Would you like more information about hospice services?

Yes
No

23. Is the patient that you are caring for receiving home/inpatient hospice?

Yes
No

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 Road
Branford, CT 06405