Family Caregiver Database 33% of survey complete. Question Title * 1. Tell us about yourself. (We will not sell your information. We'll only contact you if we believe additional information about your caregiving situation will be helpful in understanding how to help you stay healthy. And, we'll send you an email in a year to update your information.) Name: City/Town: State/Province: ZIP/Postal Code: Country: Email Address: Question Title * 2. How old are you? Between 21 and 35. Between 35 and 50. Between 50 and 60. Between 60 and 70. Between 70 and 80. More than 80 years old. Question Title * 3. Your gender: Male Female Question Title * 4. Are you married? Yes. No. Question Title * 5. Do you have children still living at home? Yes No Question Title * 6. Do you adequately take care of your physical, emotional, dental and medical needs? Yes. No. Question Title * 7. If you answered "No" to the above question, why not? I just don't have the energy. Somethings gotta give--and that's what gives. I do not have health insurance. I don't have the back-up in place to leave my caree. It's not important. Other (please specify) Question Title * 8. For how many family members or friends are you caring? One Two More than two Question Title * 9. Is this your first time caring for a family member or friend? Yes. No, this is my second time. No, this is my third time. No, this is my fourth time. No, this is my fifth time. No, I've lost count. Next >>