HD Caregiver/Partner Survey

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This is a pre-screening document to determine eligibility to participate in the HD Caregiver/Partner interview. All information about you and the person you care for is kept strictly confidential. The survey is very short and will only take a few minutes to complete, thank you for your time.

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Please provide your first name or nickname by which to address you

What is your relationship to the HD patient? Are you the...? *

Spouse/Significant Other

Sibling

Parent

Friend

Daughter/Son

その他:

What sex is the HD patient *

Female

Male

How old is the HD patient? *

less than 35 years

between 35 and 59 years

60 years or older

Does the HD patient use a walker or a cane? *

Yes

Does the patient fall more than once or twice a year? *

Yes

Does the HD patient work outside the home *

Yes

Do you live with the patient? *

Yes

Has the HD patient displayed aggressive behavior? *

Yes

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