Caregiver Experience Questionnaire
Please check the responses that apply and write in additional details where requested. You may skip any question you prefer not to answer.
Contact information
Name
*
First Name
Last Name
Preferred contact method:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Caregiving Status
Which statement best describes you? (Check all that apply.)
I am currently a caregiver.
I have been a caregiver.
I expect or plan to become a caregiver in the future.
I have never been a caregiver and do not currently plan to become one.
I am unsure.
Are you a current or past caregiver?
Yes
No
Start date or approximate year:
End date or currently:
If you plan or expect to become a caregiver, when might caregiving begin?
Within 6 months
Within 1 year
More than 1 year from now
Unsure
Additional Details based on previous question if need be
About the Person You Care For
If you care for more than one person, you may complete this section for each person.
What is the person's relationship to you?
Spouse or partner
Parent or parent-in-law
Child
Sibling
Other relative
Friend or neighbor
Other
If other selected, you can provide additional details here
What is the person's age range?
Under 18
18-39
40-64
65-79
80 or older
Prefer not to answer
Does the person live with you?
Yes
No
Sometimes
Approximately how far away does the person live?
Same household
Less than 30 minutes away
30-60 minutes away
More than 1 hour away
In a residential or care facility
What is the main reason the person needs or may need care? (Check all that apply.)
Aging-related needs
Physical health condition
Disability
Memory or cognitive condition
Recovery from illness, injury, or surgery
End-of-life care
Prefer not to answer
Other
Do you need to add an additional person?
Yes
No
What is the person's relationship to you?
Spouse or partner
Parent or parent-in-law
Child
Sibling
Other relative
Friend or neighbor
Other
If other selected, you can provide additional details here
What is the person's age range?
Under 18
18-39
40-64
65-79
80 or older
Prefer not to answer
Does the person live with you?
Yes
No
Sometimes
Approximately how far away does the person live?
Same household
Less than 30 minutes away
30-60 minutes away
More than 1 hour away
In a residential or care facility
What is the main reason the person needs or may need care? (Check all that apply.)
Aging-related needs
Physical health condition
Disability
Memory or cognitive condition
Recovery from illness, injury, or surgery
End-of-life care
Prefer not to answer
Other
Caregiving Responsibilities
What type of help do you provide or expect to provide? (Check all that apply.)
Companionship or supervision
Transportation or errands
Meal preparation or housekeeping
Help with bathing, dressing, eating, or mobility
Medication reminders or health monitoring
Scheduling or attending appointments
Managing finances, insurance, or paperwork
Coordinating paid or unpaid care
Advocacy or decision-making
Other
About how many hours per week do you provide or expect to provide care?
Fewer than 5
5-10
11-20
21-40
More than 40
Unsure
Are you the primary caregiver?
Yes
No
Care is shared equally
Not sure
Who else helps or may help provide care? (Check all that apply.)
Family
Friends or neighbors
Paid in-home caregiver
Health care professionals
Community or faith-based organization
No one else
Other
Impact and Support
How has caregiving affected, or how might it affect, the following areas of your life?
Rows
Positive impact
No impact
Some difficulty
Major difficulty
Not applicable
Physical health
Emotional well-being
Work or education
Finances
Relationships or social life
What support or information would be most helpful? (Check all that apply.)
Respite care
Financial assistance or benefits information
Legal or advance-care planning
Caregiving training
Support group or counseling
Health care navigation
Workplace or school flexibility
Transportation or meal services
Home safety or accessibility resources
No support needed at this time
Other
Additional Information
Is there anything else you would like to share about your caregiving experience, concerns, or plans?
Submit
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