Family Caregiver Stress Survey Question Title * 1. On a scale from 1 to 5, with 1 being the least stressed and 5 being the most stressed, how stressed are you? 1 Least Stressed 2 3 4 5 Most stressed How stressed are you? How stressed are you? 1 Least Stressed How stressed are you? 2 How stressed are you? 3 How stressed are you? 4 How stressed are you? 5 Most stressed Question Title * 2. What's the cause of your stress? Check as many as appropriate. A family member recently received a diagnosis I am really lonely I can't afford to hire enough help I don't have enough help I don't have enough money I don't have enough time I don't have enough time for other family members I don't sleep well at night I feel lost I haven't had a break I miss my life I'm battling the health care bureaucracy I'm facing a difficult decision I'm fighting the insurance company red tape I'm not confident in what I'm doing I'm trying to keep my job My caree has died My caree is dying My caree's care needs are overwhelming My caree's health is declining My family (excluding my caree) My own health is suffering The holidays Please add your own reason. You also can share more about your situation. Question Title * 3. Tell Us Your Zip or Postal Code ZIP/Postal Code Question Title * 4. Is this your first time taking our survey? Yes No Done
