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Care Survey 2.0


Care Survey

If you provide care for someone with dementia, we need your help to understand more about dementia and how care is provided so that treatment (both drug and management strategies) can better address what is happening in your lives.

Each person's experience with dementia is unique; however, we can interpret this individual experience to provide new insight into dementia and care.

The following questionnaire may take about 3 to 5 minutes to complete. If you wish to change your answers, simply go back and edit.

We appreciate your participation.



1.How old are you?
2.Please indicate your gender:


3.How long have you been the main care provider?





4.What is your relationship to the person you care for?






5.Does the person with dementia live with you?


6.How are you coping with the responsibility at hand?



7.Do other people help you provide care?


8.How old is the person you care for?
9.Please indicate the gender of the person you care for:


10.Has the person you care for been diagnosed with dementia?


11.Is the person you care for taking a medication for dementia?


12.Of the following five stages, which stage would you place the person you are caring for?





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Last updated April 9, 2014
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