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Name
Label/Question
1.

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


Name
Label/Question
2.

SITE NUMBER

SITE NUMBER

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


Name
Label/Question
3.

PAGE NUMBER

PAGE NUMBER

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


Name
Label/Question
4.

LOG NUMBER

LOG NUMBER

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


Name
Label/Question
5.

DATE CONTACTED

DATE CONTACTED

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


Name
Label/Question
6.

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.


Name
Label/Question
7.

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.


Name
Label/Question
8.

SCREENING ID

SCREENING ID

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


Name
Label/Question
9.

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.


Name
Label/Question
10.

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.


Name
Label/Question
11.

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


Name
Label/Question
12.

DATE OF INTERVIEW

Date of Interview

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


Name
Label/Question
13.

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.


Name
Label/Question
14.

CG SEX

5. Sex of the caregiver

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


Name
Label/Question
15.

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.


Name
Label/Question
16.

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.


Name
Label/Question
17.

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.


Name
Label/Question
18.

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.


Name
Label/Question
19.

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.


Name
Label/Question
20.

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.


Name
Label/Question
21.

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.


Name
Label/Question
22.

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.


Name
Label/Question
23.

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.


Name
Label/Question
24.

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.


Name
Label/Question
25.

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.


Name
Label/Question
26.

CR MEMORY PROBLEM

12. Have you been told by a doctor or have you noticed that (CR) has a memory problem?

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


Name
Label/Question
27.

YEARS TAKEN CARE OF CR

13. How many years have you taken care of (CR)? ____ years Exclude if less than 6 months.

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


Name
Label/Question
28.

CG SINCE

14. So you've been a caregiver since ________ (year)

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


Name
Label/Question
29.

CR ON WAITING LIST NH

15. Is (CR) on a waiting list for a nursing home or other live-in institution?

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


Name
Label/Question
30.

PLANNING TO PLACE CR NH

If (CR) is on a waiting list for a nursing home or other live-in institution. 15.1. When are you planning to actually place (CR) into the institution? __________________ ... (view details)

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


Name
Label/Question
31.

IMMINENT PLACEMENT IN NH

16. Is the caregiver excluded due to imminent placement into nursing home or other live-in institution?

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


Name
Label/Question
32.

HOURS DAY CARING FOR CR

17. On a typical day, how many hours do you spend directly caring for or supervising (CR)? ________ hours Exclude if less than 4 hours. ... (view details)

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


Name
Label/Question
33.

OTHER STUDY FOR MH

18. Are you currently in a study to help you take care of (CR)?

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


Name
Label/Question
34.

STUDY TO ASSIST YOU HLTH

If you currently in a study to help you take care of CR, 18.1. Is this a study to assist you with your physical or mental health?

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


Name
Label/Question
35.

CAN YOU BE REACHED AT PN

19. Can you be reached at this phone number if I needed to contact you?

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


Name
Label/Question
36.

PN WHERE YOU CAN BE REACH

If you cannot be reached at this phone number if I needed to contact you, 19.1. Is there a phone number where I can reach you?

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


Name
Label/Question
37.

PLANNING TO MOVE

20. Are you planning to move away from the area where you live in the next year and a half?

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


Name
Label/Question
38.

HOW IS YOUR PHYSICAL HEAL

I am going to ask you about your health. These are questions that I ask everyone. 21. How is your physical health?

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


Name
Label/Question
39.

CG HOSP OVERNIGHT

I am going to ask you about your health. These are questions that I ask everyone. 22. Have you been in the hospital overnight more than three times in the past year? ... (view details)

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


Name
Label/Question
40.

CG CURRENTLY HAVE CANCER

I am going to ask you about your health. These are questions that I ask everyone. 23. Do you currently have any type of cancer?

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


Name
Label/Question
41.

CG RECEIVING CHEMOTHERAPY

If you currently have any type of cancer, 23.1. Are you receiving chemotherapy, other than tamoxifen, radiation therapy for your cancer? ... (view details)

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


Name
Label/Question
42.

PROB USING THE TELEPHONE

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 24. Using the telephone? ... (view details)

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


Name
Label/Question
43.

PROB SHOPPING

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 25. Shopping? ... (view details)

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


Name
Label/Question
44.

PROB FOOD PREPERATION

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 26. Food preparation? ... (view details)

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


Name
Label/Question
45.

PROB HOUSEKEEPING

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 27. Housekeeping? ... (view details)

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


Name
Label/Question
46.

PROB DOING LAUNDRY

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 28. Doing laundry? ... (view details)

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


Name
Label/Question
47.

PROB TRAVELING INDEPENDTL

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 29. Traveling independently by car or bus? ... (view details)

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


Name
Label/Question
48.

PROB PAYING BILLS

The next set of questions are about (CR). I would like to know, if you were not able to help him/her, would (CR) need assistance with any of the following tasks? IADL Tasks 30. Paying bills or handling money? ... (view details)

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


Name
Label/Question
49.

HELP IN OUT OF BED

The next set of questions are also about (CR). These questions are more personal, and some people feel a bit uncomfortable answering them. We ask these questions so that we can tell whether we are the right program for you. If you do not f... (view details)

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


Name
Label/Question
50.

HELP BRUSHING TEETH

The next set of questions are also about (CR). These questions are more personal, and some people feel a bit uncomfortable answering them. We ask these questions so that we can tell whether we are the right program for you. If you do not f... (view details)

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

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