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* 1. Please enter your initials:

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* 2. Please enter the initials of the person you provide care for:

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* 3. Please select your loved one's service provider (e.g. day program, community-based network, etc.):

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* 4. Do you feel that because of the time you spend with your relative that you don’t have enough time for yourself?

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* 5. Do you feel stressed between caring for your relative and trying to meet other responsibilities (work/family)?

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* 6. Do you feel angry when you are around your relative?

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* 7. Do you feel that your relative currently affects your relationship with family members or friends in a negative way?

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* 8. Do you feel strained when you are around your relative?

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* 9. Do you feel that your health has suffered because of your involvement with your relative?

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* 10. Do you feel that you don’t have as much privacy as you would like because of your relative?

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* 11. Do you feel that your social life has suffered because you are caring for your relative?

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* 12. Do you feel that you have lost control of your life since your relative’s illness?

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* 13. Do you feel uncertain about what to do about your relative?

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* 14. Do you feel you should be doing more for your relative?

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* 15. Do you feel you could do a better job in caring for your relative?

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