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Caregiver Survey
A survey to help us assess the demographic and needs of caregivers in the WNY area.
* Indicates required question
Email
*
Your email
Who are you a caregiver for?
A parent
A child
A grandparent
A friend
A family member
A neighbor
Other:
Clear selection
How old are you?
20-25
26-30
30-39
40-49
50-59
60-69
70-79
80-89
90 or older
Clear selection
Did you plan on caring for you loved one?
Yes
No
Clear selection
If you answered No above, what was the situation that caused you to become their caregiver?
Your answer
Do you have a job other than being a caregiver?
Yes, full-time
Yes- Part-time
Yes- contract or per diem
No
I am paid to be a caregiver
Clear selection
Does the person you care for live with you/ you live with them?
Yes
No
Clear selection
Do you have to physically assist your loved one? (Ex: transfer from the bed to the chair, help them up the stairs, help them stand up?)
Yes
No
Clear selection
Since becoming a caregiver, have you experienced a negative change in your mental health?
Yes
No
Clear selection
If you answered Yes above, can you explain a little more?
Your answer
How often do you exercise for 30 minutes a week? This can include a simple walk outside!
I do not have time to exercise
Once a week
Twice a week
3 or more times a week
Other:
Clear selection
Has your physical health changed since becoming a caregiver? (Ex. you have gained weight, you have new pains, you have new diagnoses etc.)
Yes
No
Clear selection
Do you feel like you are burnt out?
Yes, I need help
No, I feel like I have a good balance of everything
Not yet, but definitely on my way
Other:
Clear selection
If you would be interested in a caregiver support group and separate newsletter please leave your email below.- this is also how we will let you know if you won the gift card!
Your answer
Have you checked out our Blog posts and Forums on our website? This is a place caregivers can chat with each other and read advice.
Of course I have!
Not yet, but I am heading there now!
Clear selection
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