Chronic Illness Social Support Survey
Help us understand your experiences with social support while managing a chronic illness.
Full Name
First Name
Last Name
Age Range
*
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 and above
Gender
Female
Male
Non-binary/Other
Prefer not to say
What is your primary chronic illness?
*
How long have you been living with this illness?
*
Please Select
Less than 1 year
1-3 years
4-7 years
8-10 years
More than 10 years
Which types of social support do you currently receive? (Select all that apply)
*
Emotional support (e.g., empathy, encouragement)
Practical support (e.g., help with daily tasks)
Informational support (e.g., advice, information)
Financial support
No support
Other
Who are your main sources of support? (Select all that apply)
*
Family members
Friends
Healthcare providers
Support groups (in-person or online)
Community organizations
No support
Other
How satisfied are you with the social support you receive?
*
Not at all satisfied
1
2
3
4
Very satisfied
5
1 is Not at all satisfied, 5 is Very satisfied
Please share any additional comments about your experiences with social support while managing your chronic illness.
Submit Survey
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