* 1. Is this information relevant?

* 2. Do you understand this information?

* 3. What do you think about this information? Check all that apply.

* 4. Will you use this information for yourself?

* 4.1. [If yes*] How will you use this information for the person under your care (child, spouse or elderly parent)? Check all that apply.

* 5. Do you expect any benefit for the person under your care (child, spouse or elderly parent) from using this information? Check all that apply.

T