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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.

2.

SITE NUMBER

SITE NUMBER

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

3.

PAGE NUMBER

PAGE NUMBER

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

4.

LOG NUMBER

LOG NUMBER

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

5.

DATE CONTACTED

DATE CONTACTED

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

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.

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.

8.

SCREENING ID

SCREENING ID

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

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.

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.

11.

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

12.

DATE OF INTERVIEW

Date of Interview

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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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