Caregiver Health Management Survey Form.
Share your general caregiving routines, challenges, confidence, and support needs.
What is your relationship to the person you care for?
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Parent or parent-in-law
Spouse or partner
Child
Other family member
Friend or neighbor
Professional caregiver
Other
How long have you been caregiving?
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Less than 6 months
6 months to less than 1 year
1 to less than 3 years
3 to less than 5 years
5 years or more
About how many hours per week do you typically spend caregiving?
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Less than 5 hours
5–9 hours
10–19 hours
20–39 hours
40 hours or more
Which health-management tasks do you support? Select all that apply.
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Keeping track of appointments
Coordinating care or services
Supporting daily routines
Organizing general care-related information
Communicating with care providers
Encouraging healthy routines, such as meals, movement, or rest
Other
How confident do you feel managing caregiving-related health routines?
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1
2
3
4
5
How difficult do you find managing caregiving-related health routines?
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1
2
3
4
5
What challenges do you commonly experience? Select all that apply.
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Not enough time
Coordinating schedules or services
Finding clear, reliable general information
Balancing caregiving with work or other responsibilities
Stress or feeling overwhelmed
Limited help from others
Keeping up with changing routines
Other
Which sources of support do you currently use? Select all that apply.
*
Family or friends
Caregiving or community support groups
Community organizations
Respite or in-home support services
Workplace support or flexibility
Online caregiving resources
I do not currently use support
Other
What additional support or resources would be most useful to you?
Please acknowledge: I understand that participation is voluntary and my responses concern general caregiving experiences, not a request for medical advice.
*
I acknowledge
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