Other Family Members

Which of the following health or medical conditions is anyone in your family currently experiencing?

• Acne
• Acute Coronary Syndrome/Heart Attack
• ADD/ADHD
• Age Related Memory Loss (moderate or severe)
• Alzheimer's/Dementia
• Allergies
• Anaphylaxis/Severe Allergy
• Arthritis: Osteoarthritis/Degenerative arthritis
• Arthritis: Rheumatoid Arthritis (RA)
• Asthma
• Autism
• Bipolar Disorder
• Cancer
• Chronic Pain
• COPD (including Chronic Bronchitis and Emphysema)
• Depression
• Diabetes
• Eczema
• Enlarged Prostate/Benign Prostate Hyperplasia
• Eye Problems/Eye Disease (including Cataracts, Glaucoma, and other eye/vision problems)
• Heart Disease
• Hepatitis C
• High Cholesterol/High Triglycerides
• Hypertension/High Blood Pressure
• Multiple Sclerosis
• Nutritional Deficiency
• Obesity
• Parkinson's Disease
• Psoriasis
• Schizophrenia
• Seizures/Epilepsy
• Shingles
• Stroke

What are the ages of your family members who are experiencing these conditions?

• Less than 24 months old
• 2 to 11 years old
• 12 to 17 years old
• 18 to 49 years old
• 50 to 64 years old
• 65 years or older

What types of caregiver support do you provide for any family members with a health or medical condition? 

• DOCTORS & TREATMENTS
• Administer or monitor medications
• Buy medication or refill prescriptions
• Discuss conditions or treatments with their doctor
• Encourage doctor visits
• Make doctor appointments
• Make sure vaccines are received
• Monitor state of condition
• Provide transportation to doctor/medical treatment 
• Research health information


• PERSONAL ASSISTANCE
• Arrange for outside services
• Assist with daily household chores
• Assist with personal care (e.g., bathing, dressing, eating)
• Manage finances or provide financial support


• Other support
• I don’t provide caregiver support 

Thinking about the individuals for whom you provide caregiver support, which of these conditions are they currently experiencing?

(Selections from Other Family Members Health Conditions)
• Acne
• Acute Coronary Syndrome/Heart Attack
• ADD/ADHD
• Age Related Memory Loss (moderate or severe)
• Alzheimer's/Dementia
• Allergies
• Anaphylaxis/Severe Allergy
• Arthritis: Osteoarthritis
• Arthritis: Rheumatoid Arthritis (RA)
• Asthma
• Autism
• Bipolar Disorder
• Cancer
• Chronic Pain
• COPD (including Chronic Bronchitis and Emphysema)
• Depression
• Diabetes
• Eczema
• Enlarged Prostate/Benign Prostate Hyperplasia
• Eye Problems/Eye Disease (including Cataracts, Glaucoma, and other eye/vision problems)
• Heart Disease
• Hepatitis C
• High Cholesterol/High Triglycerides
• Hypertension/High Blood Pressure
• Multiple Sclerosis
• Nutritional Deficiency
• Obesity
• Parkinson's Disease
• Psoriasis
• Schizophrenia
• Seizures/Epilepsy
• Shingles
• Stroke
• Other health condition

How long have you been providing caregiver support for anyone with a health or medical condition?

• Less than 6 months
• 6 months to less than a year
• 1 year to less than 2 years
• 2 years to less than 5 years
• 5 years to less than 10 years
• 10 or more years

Do you live in the same household as any person you provide caregiver support for?

• Yes
• No

How involved are you in discussions about medical choices or treatment decisions for any person you provide caregiver support for?

• Very involved
• Somewhat involved
• Not very involved
• Not at all involved

Which of the following types of medical professionals have you taken a child to see in the last 12 months?

• Allergist
• Dentist
• Ear, Nose & Throat Specialist
• Nurse Practitioner/Physician’s Assistant
• Pediatrician
• Primary Care Doctor (e.g., Family or Internal medicine, or General Practice)
• Psychiatrist
• Other medical professional
• None in last 12 months

RX

• Adderall
• Concerta
• Daytrana
• Intuniv
• Ritalin
• Strattera
• Generic prescription
• Other prescription

OTC

• Allegra
• Rhinocort
• Claratin
• Zyrtec
• Generic prescription
• Other non-prescription
 

Rx

• EpiPen
• Singulair
• Generic prescription
• Other prescription
 

Rx

• Advair
• Pulmicort
• Singulair
• Generic prescription
• Other prescription
 

OTC

• Advil
• Benadryl
• Motrin
• Robitussin
• Sudafed
• Tylenol
• Delsym
• Dimetapp
• Little Colds
• Little Noses
• Mucinex
• Pediacare
• Triaminic
• Generic prescription
• Other non-prescription
  

OTC

• Centrum
• Disney Multivitamins
• Flintstones
• L'il Critters
• One-A-Day
• Generic prescription
• Other non-prescription

How much do you agree or disagree with each of the following statements?

Agree a lot, Agree a little, Neither agree nor disagree, Disagree a little, Disagree a lot

• As a preventative measure it is important my children take vitamins every day
• I actively participate in decisions regarding the types of vaccines my children receive
• I always take my child to the doctor when he/she is sick
• I trust my doctor to be cautious about over prescribing medications for my children
• I will only buy the brands of medicine recommended by my child’s doctor
• When a prescription drug becomes available as an over-the-counter medication, I will switch my children to the over-the-counter version
• The benefits of having my children immunized outweigh the risks