Exit this survey >> Family Caregiver Database 33% of survey complete. * 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: * 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. * 3. Your gender: Male Female * 4. Are you married? Yes. No. * 5. Do you have children still living at home? Yes No * 6. Do you adequately take care of your physical, emotional, dental and medical needs? Yes. No. * 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) * 8. For how many family members or friends are you caring? One Two More than two * 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 >>