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* 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.)

* 2. How old are you?

* 3. Your gender:

* 4. Are you married?

* 5. Do you have children still living at home?

* 6. Do you adequately take care of your physical, emotional, dental and medical needs?

* 7. If you answered "No" to the above question, why not?

* 8. For how many family members or friends are you caring?

* 9. Is this your first time caring for a family member or friend?

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