Alzheimer’s Family Caregivers: Psychological Experience and Support Needs Survey

For more information concerning this research you should contact Dr. Brown at 804-828-6754 or at kwbrown@vcu.edu. (All questions marked with * are required.)

WE ASK THAT YOU CLICK ON THE "SUBMIT BUTTON" EVEN IF YOU DO NOT COMPLETE THE SURVEY.

THANK YOU!

1. Are you the main person providing care for someone with Alzheimer’s Disease (AD)? Required Question

	Yes
	No

2. Where does this person live? Required Question

4. If this person lives in your home or in their home, do you have some type of help with the caregiving responsibilities?

Yes, alwaysYes, oftenYes, occasionallyNo, never

5. If you have assistance, how helpful do you find it to be?

6. How is this person with AD related to you? (Check ONE) Required Question

7. How long have you been providing care for this person?

Years
Months

8. Approximately how long has this person been experiencing memory-related problems?

Years
Months

9. On average, how many days per week do you provide care for this person?

10. On the days that you provide care for this person, on average, how much care do you provide?

11. Overall,

	Not at all	A little	Somewhat	Very much	Extremely
__to what extent does this person depend on you for activities of daily living, such as bathing, dressing, preparing meals, shopping, etc?
__how burdened do you feel in caring for this person?

12. What are the problems you experience as a consequence of caring for this person? (Check all that apply)

	It affects my relationship with this person in a negative way
	It affects my relationship with other family members or friends in a negative way
	It affects my health in a negative way
	It is stressful for me
	It affects my job/work in a negative way
	It affects my finances in a negative way
	I don’t have enough time for myself
	I don’t have enough time for my family and friends
	Other (please specify)

13. Do you have emotional support from any of the following? (Check all that apply).

14. Where do you get your information about resources for caregivers of Alzheimer’s Disease patients? (Please indicate your top THREE sources.)

15. Are you getting the information you need?

	Yes
	No. Please explain why not

16. How much would you say that you know about the services that are available through the Alzheimer’s Association?

A lot	Some	A little	Nothing at all

17. How much would you say that you know about the services that are available through your local Area Agency on Aging?

A lot	Some	A little	Nothing at all

	Their home
	Your home
	Assisted living facility
	Nursing home
	Other (please specify)

Not at all helpful	A little helpful	Somewhat helpful	Very helpful	Extremely helpful

	Friend, neighbor, or other non-relative
	Spouse/partner
	Mother/father
	Mother-in-law/father-in-law
	Grandparent
	Sister/Brother
	Other relative (please specify)

	Individual, family, or couples counseling
	Psychotherapy or psychiatric treatment
	Support groups
	Family
	Friends
	Church/Synagogue/Mosque/Temple/etc.
	Other (please specify)

	Alzheimer's Association
	Social Services agency
	Area Agency on Aging
	Friends or neighbors
	Family
	Co-workers
	Physicians
	Telephone book
	Internet
	TV/Radio
	Other organization for older adults. Which one(s)?
	Other health care professionals. Which one(s)?
	Newspaper/magazines. Which one(s)?
	Religious organizations. Which one(s)?
	Civic or community organizations. Which one(s)?
	Other sources. Which one(s)?