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Follow-Up Questionnaire
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We truly hope you found this program to be of help in your caregiving journey. Please take a few minutes to answer the questions below on how you and your loved one are doing. Some of the questions you will answer may sound familiar. Your answers will help us understand how we may continue to support you and make improvements for caregivers like you to come.
Caregiver Name:
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First Name
Last Name
Cell phone number:
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Please tell us a little bit more about how you are feeling as a caregiver.
On a scale of 1-10, how would you rate your stress level?
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(Rate on a scale from 1-10, where 1 = no stress and 10 = very high stress
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2
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9
10
As the primary caregiver, where does the source of your stress come from?
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Caregiving responsibilities
Not related to Caregiving responsibilities
Both
During the past week, have you had severe fatigue or exhaustion?
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Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or moderate amount of time (3-4 days)
Most or all of the time (5-7 days)
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things:
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Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless:
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Not at all
Several days
More than half the days
Nearly every day
Hidden
PHQ2_Score
How often do you feel that you lack companionship?
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Never
Rarely
Sometimes
Frequently
All of the time
How often do you feel left out?
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Never
Rarely
Sometimes
Frequently
All of the time
How often do you feel isolated from others?
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Never
Rarely
Sometimes
Frequently
All of the time
How many times did you go to an emergency room that did not result in hospitalization in the past three months?
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0
1
2
3+
How many times did you stay in a hospital overnight or longer in the past three months?
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0
1
2
3+
How many nights in total did the person you care for spend in the hospital?
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Questions regarding the person cared for:
In the last 3 months, has a lack of reliable transportation kept the person you care for from medical appointments, meetings, work, or from getting things needed for daily living?
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Yes
No
In the last 3 months, did the person you care for ever eat less than you felt s/he should because there wasn’t enough food at home or money for food?
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Yes
No
Has the person you care for fallen in the past 3 months?
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Yes
No
Do you think the person you care for may fall in the next 3 months?
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Yes
No
How many times did the person you care for go to an emergency room that did not result in hospitalization in the past three months?
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0
1
2
3+
How many times did the person you care for stay in a hospital overnight or longer in the past three months?
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0
1
2
3+
How many nights in total did the person you care for spend in the hospital?
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Does the person you care for live alone?
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Yes
No
How often does the person you care for see or talk to people she/he cares about and feels close to within the last 3 months?
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Less than once a week
1-2 times a week
3-5 times a week
More than 5 times a week
Care 4 Caregivers Program Feedback:
Have your respite care needs been addressed through working with us?
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Yes
No
In progress
I didn’t have respite care needs
I could use some help now!
Were we able to address your Medicare / Medi-Cal questions?
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Yes
No
In progress
I didn’t have respite care needs
I could use some help now!
How satisfied are you with the quality of care support services you have received from the Care 4 Caregivers team in the last three months?
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(Rate on a scale from 1-10, where 1 = not satisfied and 10 = very satisfied)
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10
How likely is it that you would recommend Care 4 Caregivers to a friend, colleague, or a family member?
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(Rate on a scale from 1-10, where 1 = not likely and 10 = very likely)
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9
10
I have more information and choices because of the services/assistance I received.
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Agree
Neither agree nor disagree
Disagree
Not Applicable
I am more confident that I will be able to manage my life better because of the services/assistance I received.
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Agree
Neither agree nor disagree
Disagree
Not Applicable
The services/assistance I received improved my health, safety, and/or well-being.
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Agree
Neither agree nor disagree
Disagree
Not Applicable
Has using Care 4 Caregivers improved your ability to care for your loved one?
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Yes
No
We would love to hear more about how the Care 4 Caregivers program helped you as a caregiver. Please share your story with us!
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