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Name
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Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

SITE NUMBER

SITE NUMBER

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

PAGE NUMBER

PAGE NUMBER

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

LOG NUMBER

LOG NUMBER

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

DATE CONTACTED

DATE CONTACTED

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

AGREED TO BE SCREENED

AGREED TO BE SCREENED

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

WHY NOT SCREENED

WHY NOT SCREENED

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

SCREENING ID

SCREENING ID

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

ELIGIBLE FOR REACH

ELIGIBLE FOR REACH

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

AGREED TO BE IN REACH

AGREED TO BE IN REACH

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening Log Sheet.

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

DATE OF INTERVIEW

Date of Interview

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

START OF INTERVIEW

Start of Interview (Military Time)

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

CG SEX

5. Sex of the caregiver

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

TAKE OF OTHER ADULT

6. Do you take care of any other adult in addition to (CR)?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

OTHER ADULT MEMORY PROBLE

If you take care of any other adult in addition to (CR), 6.1. Does he/she have memory problems?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

OTHER ADULT LIVE WITH CG

If you take care of any other adult in addition to (CR), 6.2. Does he/she live with you?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

WHICH PERSON REQUIRES MOR

If you take care of any other adult in addition to (CR), 6.3. Which person requires more time?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

PATIENT SEX

7. What is the sex of (CR)?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

CG DATE OF BIRTH

Caregiver Date of Birth 8. What is your date of birth? __ __ / __ __ / __ __ month day year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

CR DATE OF BIRTH

Care Receiver Date of Birth 9. What is the date of birth for (CR)?: __ __ / __ __ / __ __ month day year

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

CG RELATED TO PT

10. Are you related to (CR)?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

RELATIONSHIP TO PATIENT

If you are you related to CR, 10.1. What is your relationship to (CR)?

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

RELATION TO PATIENT SPEC

What is your relationship to (CR)? Other 10.1.1. Specify: __________________

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

PATIENT LIVE WITH CG

11. Does (CR) live with you? We consider living together as sharing cooking facilities.

Taken from: Resources for Enhancing Alzheimer's Caregiver Health, 1996-2001, Baseline and Follow-Up Data - Screening.

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