Csha.ca

CAREGIVER QUESTIONNAIRE
Registration Information This page is to be kept at Study Centre
STUDY SUBJECT
Complete using CSHA-3 Subject Information Sheet and information fromcoordinator Address:
D.O.B.: / /
CAREGIVER Complete at time of phone call if you have not already confirmed this information
_______________________________________________________________ Address:
_______________________________________________________________Town/City Are you involved in caring for (____)?
Does (____) need care?
1 Yes
Would you provide care
if this was needed?
Are you the main caregiver?
Who is the main person who helps
(or would help) with care?
English 3
Part of Clinical
Frail sample
CANADIAN STUDY OF HEALTH
AND AGING-3
CAREGIVER
QUESTIONNAIRE
Canadian Study of Health & Aging - 3
CAREGIVER QUESTIONNAIRE
Identifying Information
STUDY SUBJECT Complete using CSHA-3 Subject Information Sheet
Date of CSHA-3 Screening Interview:
CAREGIVER Complete before the interview
Caregiver sex:
Care needed?:
Main caregiver or would be if needed?
Thank you for agreeing to talk to us. I would like to spend some time talking to you
about (___________ ) and his/her situation, and also about the help that you provide. I
would like to begin by first asking you a few questions about yourself.
What is your relationship to (_______________)?
When were you born?
What is your current marital status?
How many years of education did you complete? Yrs
Do you live in the same house as (_________ ______)?
How many people in total
How many people in total live in
live in your household?
(_______)’s household?
How many people in total live in your
household? Specify number: ________
Next, I want to ask you about how ( ) manages in (his/her) daily life. I will mention a
number of common, daily activities, and for each I want you to say if ( ) can manage
this without help, or he/she needs some help, or whether he/she cannot do it at all, that is,
someone has to do this for him/her. | (SHOW CARD #1). (If the respon dent has difficu lty in
selecting the appropriate resp onse category, read the exa mples in parentheses belo w each option. On ly use
these if help is required, or if you feel that the respondent has not understood the response options.)
IF THE PERSON NEEDS HELP OR CANNOT DO A TASK, ASK: Has anyone helped
him/her with ( the task ) during the last month? Include yourself and any family
members, friends and neighbours, paid workers, visiting nurses, etc. How many people
have helped? Can you tell me the relationship of those who help most often? How many
times do you/they help each month?
Please code the caregiver as Self. You may abbreviate the relationship to ( ) as: SE = Self;W=Wife; H=Husband; D=Daughter; So=son; B=Brother; Si=Sister; F=Friend; DIL=Daughter-in-law; SOL=Son-in-law; BIL=Brother-in-law; PC=Paid caregiver; V=Volunteer; O=Other. Task (In last month)
Has anyone helped ( )
Relationship to
How many times
with the task during the
do you/they help
last month?
per month?
a. Can ( ) eat .
How many?
0 or is he/she c ompletely unable to feed b. Can ( ) dress and
How many?
undress .
2 without any he lp (pick out cloth es, dress, undress) 0 or is he/she c ompletely unable to dress and Task (In last month)
Has anyone helped ( )
Relationship to
How many times
with the task during the
do you/they help per
last month?
c. Can ( ) take care
How many?
o f hi s/ h er o w n
appearance, for example,
combing his/her hair and
(for men shaving ) .
d. Can ( ) walk .
How many?
(from a person, or using a walker, crutches or e. Can ( ) get in and
How many?
out of be d .
0 or is he/she c ompletely unable to get in and out of bed unless someone lifts him/her? Task (In last month)
Has anyone helped ( )
Relationship to
How many times
with the task during the
do you/they help per
last month?
f. Can ( ) take a
How many?
bath or showe r .
0 or is he/she c ompletely unable to bathe? g. Can ( ) go to
How many?
bathro om or to ilet .
0 or is he/she c ompletely unable to use the h. Can ( ) use the
How many?
telephon e .
emergency, but needs special pho ne or help in getting numbers or dialing) 0 or is he/she c ompletely unable to use the phone? Task (In last month)
Has anyone helped ( )
Relationship to
How many times
with the task during the
do you/they help per
last month?
i. Can ( ) get to
How many?
places out of walking
distance .
(needs som eone to he lp or go with him/her unable to travel unless special arrangements are made? j. Can ( ) go
How many?
shopping for his/her
groceries or clothes
(assuming they have
transpo rtation) .
1 with some h elp (needs someone to go with him/her on a ll shopping trips) 0 or is he/she c ompletely unable to do any shopping? How many?
p r ep a re h is /h e r o w n
meals .
2 without any he lp (plans and c ooks full (can do some things but not prepare full meals) Task (In last month)
Has anyone helped ( )
Relationship to
How many times
with the task during the
do you/they help per
last month?
l. Can ( ) do
How many?
his/her ho usewo rk .
2 without any he lp (scrubs floors , etc.) 1 with some h elp (can do light work but not heavy work) m. Can ( ) take
How many?
his/her ow n medicin e .

2 without any he lp (in the right dose at the right time) 1 with some h elp (can take me dication if someone prepare s it and remind s him/her to take it) n. Can ( ) handle
How many?
his/her ow n mone y .
(can manage day-to- day buying but needs help with cheque book CARE MANAGEMENT
7. How often, on average, do you. | (SHOW CARD #2)
a) . schedule Home Care or other support
workers for (___________)
b) . make appointments for (_________)
c) . check to see how (_____) is doing,
either in person or by telephone
d) Is there anything else you do to manage care for ( )?
(Record verbatim an d indicate freq uency)
How long ago did you first have to start helping (him/her) do things that (he/she) was no
longer able to do?
Who would take over your role of caring for ( ) if you were not available?
(Code relationship to care recipient)
THE CAMDEX
The following questions relate to changes in ( )’s awareness, behaviour and character
during the past five years. These changes do not always appear in late life, and may not be
relevant to him/her, but we have to ask these of everybody in order to be consistent.
In the past five years:
Have you noticed any changes in his/her personality,
No . . . . . . . . . . . . . . . . . . . 2 7 such as the way he/she behaves socially?
Yes . . . . . . . . . . . . . . . . . . 1 8 Specify type of change:
Has there been any noticeable exaggeration
No . . . . . . . . . . . . . . . . . . . 2 7 in his/her normal character?
Yes . . . . . . . . . . . . . . . . . . 1 8 Has he/she become more (or less) changeable in mood? No . . . . . . . . . . . . . . . . . . 2 7
Yes. . . . . . . . . . . . . . . . . . . 1 8 Has he/she become more (or less) irritable or angry?
No . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 PFQ1. Has he/she become more aggressive?
No . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 Has he/she become more stubborn or perhaps
No . . . . . . . . . . . . . . . . . . 2 7 a little awkward? Or less?
Less . . . . . . . . . . . . . . . . . 1 8 More . . . . . . . . . . . . . . . . . 0 Does he/she have difficulty remembering
short lists of items, e.g. a shopping list?
Slight difficulty . . . . . . . . 1 8Great difficulty . . . . . . . . . 0 If difficulty, How long has this difficulty
been present?
NA . . . . . . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . . . . . . 888 Does he/she have difficulty remembering recent No difficulty . . . . . . . . . . . . . . . . 2 7
events (e.g., when he/she last saw you, or what
Slight difficulty . . . . . . . . . . . . . 1 8 happened the day before?)
Great difficulty . . . . . . . . . . . . . . 0 If difficulty, How long has this difficulty
been present?
NA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . 888 Does he/she have difficulty interpreting
No difficulty . . . . . . . . . . . . . . . . 2 7 surroundings (e.g. knowing where he/she is,
Slight difficulty . . . . . . . . . . . . . 1 8 or discriminating between different types
Great difficulty . . . . . . . . . . . . . . 0 of people, such as doctors, visitors, relatives?)
Does he/she have difficulty finding the way
No difficulty . . . . . . . . . . . . . . . . 2 7 about home (or ward), e.g. finding the toilet?
Slight difficulty . . . . . . . . . . . . . 1 8Great difficulty . . . . . . . . . . . . . . 0 Does he/she have difficulty finding the way
No difficulty . . . . . . . . . . . . . . . . 2 7 around the neighbourhood, e.g. to the shops
Slight difficulty . . . . . . . . . . . . . 1 8 near home?
Great difficulty . . . . . . . . . . . . . . 0 If no memory problems in questions 247-251, omit questions 252, 252a, 253a & 253b and code 6 or 666 Have these changes developed gradually
Gradually . . . . . . . . . . . . . . . . . . 2 6 or did they come on suddenly?
Suddenly . . . . . . . . . . . . . . . . . . . 1 7 When did these changes first appear?
NA . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . 777DK When did his/her memory problems
first affect his/her social or family life?
NA . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . 777DK Has he/she consulted a doctor about his/her memory problems?
1 Yes 2 No
If yes, When was the first consultation?
NA . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . 777DK 12.
Has there been a more general decline in
No . . . . . . . . . . . . . . . . . . . 2 7 his/her mental functioning? For example,
Yes . . . . . . . . . . . . . . . . . . 1 8 is it less clear or sharp?
Does he/she tend to talk about what happened
No . . . . . . . . . . . . . . . . . . . 2 7 long ago rather than in the present?
Sometimes . . . . . . . . . . . . 1 8Often . . . . . . . . . . . . . . . . . 0 When speaking, does he/she have difficulty
No . . . . . . . . . . . . . . . . . . . 2 7 finding the right word, or use wrong words?
Yes . . . . . . . . . . . . . . . . . . 1 8 Does he/she seem to find it more difficult
No . . . . . . . . . . . . . . . . . . . 2 7 to make decisions lately?
Yes . . . . . . . . . . . . . . . . . . 1 8 Is there a loss of any special skill or
No . . . . . . . . . . . . . . . . . . . 2 7 hobby he/she could manage before?
Yes . . . . . . . . . . . . . . . . . . 1 8 Does his/her thinking seem muddled?
No . . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 PFQ2. Does he/she have problems maintaining a
No . . . . . . . . . . . . . . . . . . . 2 7 train of thought?
Yes . . . . . . . . . . . . . . . . . . . .1 8 PFQ3. Has he/she become more suspicious?
No . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . 1 8 Has he/she complained unjustifiably of being
persecuted or spied on by others?
286a. If yes, How long has this been present?
Duration in months NA . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . 888 Has he/she been troubled by voices or visions not
experienced by others?
287a. If yes, How long has this been present?
Duration in months NA . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . 888 14.
Are there periods lasting days or weeks when
his/her thinking seems quite clear, but then
becomes muddled?
If YES:
272.
Are there brief episodes during 24 hours when
he/she seems worse, and then times when
his/her thinking seems quite clear?
Is the confusion worse towards dusk or in
the evening?
How long has this difficulty been present?
Duration in months NA . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . 888 Does he/she show a loss of interest or
enjoyment in things in general?
Do you think that he/she is depressed?
No . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . 1 8 16.
Does he/she tend to get up and wander at night
or at any other time?
On a scale of 1 to 5 rate his/her tendency to snore:
Virtually never snores . . . . . . . . . . 1Occasionally snores softly . . . . . . . 2Moderate snorer . . . . . . . . . . . . . . . 3Quite severe snoring is usual . . . . . 4Severe, frequent and bizarre snoring 5R . . . . . . . . . . . . . . . . . . . . . . . . . . . 7DK . . . . . . . . . . . . . . . . . . . . . . . . . 8 Was he/she ever diagnosed as having obstructive
No . . . . . . . . . . . . . . . . . . . 2 7 sleep apnea?
Yes . . . . . . . . . . . . . . . . . . 1 8 Has he/she ever passed out and then had a brief
No . . . . . . . . . . . . . . . . . . . 2 7 weakness or difficulty with speech, memory or vision? Yes . . . . . . . . . . . . . . . . . . 1 8
Does he/she have a tendency to fall?
No . . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 Has he/she ever had a stroke?
No . . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 If any answer to 288 - 290 is ‘Yes’, ask 291. If all answers are ‘No’, code 666 and 6, below.
How long ago did this occur?
Months ago NA . . . . . . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . . . . . . 888 Does he/she have problems with incontinence?
No . . . . . . . . . . . . . . . . . . . 3 6Wets occasionally . . . . . . . 2 7Wets often . . . . . . . . . . . . 1 8Doubly incontinent . . . . . . 0 If no problem has been established anywhere in Questions 238-291, code 6 and 666 for questions 292-294.
292. Does he/she have trouble getting about since the onset of
the above difficulties?
No difficulty . . . . . . . . . . . 2 6 Slight difficulty . . . . . . . . 1 7 Great difficulty . . . . . . . . . 0 8 293. You have indicated some changes in ( ). Can you tell me what was the first change
noticed in his/her behaviour? (Record answer in full)
How long ago was that?
Time ago in months NA . . . . . . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . . . . . . 888 When, in your judgement, was his/her mental ability
last quite normal?
NA . . . . . . . . . . . . . . . . . . . . . . . 666R . . . . . . . . . . . . . . . . . . . . . . . . . 777DK . . . . . . . . . . . . . . . . . . . . . . . 888 18. CAMDEX Part II.
Pertaining to the Subject's Past History I would now like to ask you about other aspects of (___________)’s health in the past.
Has he/she ever been told by a doctor that he/she
No . . . . . . . . . . . . . . . . . . . 2 7 had high blood pressure?
Yes . . . . . . . . . . . . . . . . . . 1 8 Has he/she ever been told by a doctor that he/she
No . . . . . . . . . . . . . . . . . . . 2 7 had had a heart attack?
One . . . . . . . . . . . . . . . . . . 1 8More than one . . . . . . . . . . 0 Has he/she ever been diagnosed as diabetic?
No . . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 Has he/she been diagnosed as having Parkinson's
No . . . . . . . . . . . . . . . . . . . 2 7 disease?
Yes . . . . . . . . . . . . . . . . . . 1 8 Is he/she currently being treated for cancer?
No . . . . . . . . . . . . . . . . . . . 2 7Yes . . . . . . . . . . . . . . . . . . 1 8 In the past 5 years, has (_____) ever had a drug treatment for Alzheimer’s disease?
If YES: What did he/she take? (Check all that apply)
Has he/she ever been unconscious after a
No . . . . . . . . . . . . . . . . . . . . 2 7 head injury?
1 injury . . . . . . . . . . . . . . . . . 1 82 injuries . . . . . . . . . . . . . . . 3 If YES, At what age?
Specify age:
Has he/she ever had seizures?
No . . . . . . . . . . . . . . . . . . . . 2 7 302a. If YES, specify age of onset:
Infantile only . . . . . . . . . . . . 1 8Past seizures only (non-infantile) . . . . . . . . . . . 3 Current seizures . . . . . . . . . . 4 Has he/she ever been a heavy smoker, say 20
No . . . . . . . . . . . . . . . . . . . . 2 7 or more cigarettes a day for a year or more?
Yes . . . . . . . . . . . . . . . . . . . . 1 8 Has he/she ever drunk alcohol such as beer,
No . . . . . . . . . . . . . . . . . . . . 2 7 wine or spirits?
Yes . . . . . . . . . . . . . . . . . . . . 1 8 Did you ever think he/she was a heavy drinker?
No . . . . . . . 2 7Yes . . . . . . . 1 8 Did drinking ever cause him/her any problems
such as losing jobs, or with driving? Yes . . . . . . . . 1 8
Has he/she ever taken pills or drugs that he/she
No . . . . . . . . . . . . . . . . . . . . 2 7 felt unable to manage without, for instance
barbiturates to help him/her sleep, or purple
Hypnotics . . . . . . . . . . . . . . . 3 hearts (amphetamines) to help him/her cope?
Barbiturates . . . . . . . . . . . . . 4 Stimulants . . . . . . . . . . . . . . 5 Others . . . . . . . . . . . . . . . . . 6 Has he/she ever had a nervous or emotional
No . . . . . . . . . . . . . . . . . . . . 2 7 illness requiring treatment?
1 episode . . . . . . . . . . . . . . . 0 8 2 episodes . . . . . . . . . . . . . . 1 3 episodes . . . . . . . . . . . . . . 3 4 episodes . . . . . . . . . . . . . . 4 5 episodes . . . . . . . . . . . . . . 5 6 or more episodes . . . . . . . . 6 Did any of his/her close relatives have trouble with memory or get very confused and have to go
into a home to be looked after?
Female relatives: mother, sisters, daughters
Male relatives: father, brothers, sons
Many services are available to help elderly people and those who care for them. Services
may be provided by the government, hospitals, private agencies or volunteer agencies. You
have probably heard of some of these: for example, Homemaker Services, In-Home
Nursing, or Self-Help Groups.
I am going to read you a list of statements about community services and I would like you
to tell me how strongly you agree or disagree with each statement.
I would rather ask my family or friends for help than use community services
________
I believe the government should support more community services to help
care for people at home
________
I am proud of being able to care for my relative with little help from
community services
________
I believe in the idea that families should care for their own and not ask
for outside help
________
No-one has told me what services are available for my relative
________
I wish there were someone who could tell me more about community
services for my relative
________
I do not have time or energy to look for community services
for my relative
________
I have been meaning to look for services but have not gotten around to it _______
Now I want to ask you about assistance or community services that ( ) or his/her family may have been using in the past year. I am
going to read a list of services, and for each, I am going to ask you whether or not they have been used to help ( ) and his/her family.
A. Has the
B. How many
C. (If not used)
Name of service
service been
times in past
(______) in past
year?
a. Homemaker
1. Is this service available in your area? 1 Yes 2 No (Go to 20b) 7 R 8 DK
2. Do you or (_____) need this service? 1 Yes (Go to C3) 2 No 7 R 8 DK
IF No and no explanation given: Why do you say that?
3. Is there a reason why you did not use a homemaking service? For example, cost,
waiting lists, you or (______)’s preference?
b. Home delivered
1. Is this service available in your area? 1 Yes 2 No (Go to 20c) 7 R 8 DK
2. Do you or ( ) need this service? 1 Yes (Go to C3) 2 No 7 R 8 DK
IF No and no explanation given: Why do you say that?
3. Is there a reason why you did not use home delivered meals? For example, cost,
waiting lists, you or (___)’s preference?
A. Has the
B. How many
C. (If not used)
Name of service
service been
times in past
(______) in past
year?
c. Home help for
1. Is this service available in your area? 1 Yes 2 No (Go to 20d) 7 R 8 DK
personal tasks
2. Do you or (_____) need this service? 1 Yes (Go to C3) 2 No 7 R 8 DK
(e.g. grooming,
If No and no explanation given: Why do you say that?
bathing)
3. Is there a reason why you did not use a home help? For example, cost, waiting lists,
you or (______)’s preference?
d. In-home nursing
1. Is this service available in your area? 1 Yes 2 No (Go to 20e) 7 R 8 DK
2. Do you or (_____) need this service? 1 Yes (Go to C3) 2 No 7 R 8 DK
If No and no explanation given: Why do you say that?
3. Is there a reason why you did not use in-home nursing? For example, cost, waiting
lists, you or (______)’s preference?
Name of service
A. Used by (______) in past
B. How many times
in past year?
e. Physiotherapy
(in the home or at a clinic)
f. Occupational therapy
(in the home or at a clinic)
g. Podiatry treatments
h. Chiropractic treatments
i. Day centre
The next questions will ask about services that you, the caregiver, may have used to help you.
Name of service
A. Have you used (the service)
B. How many times in past
in past year?
j. Respite care for
( )in home
k. Respite care for
( ) in hospital
or nursing home
l. Information or support
service (e.g. the Web,
Alzheimer Society, the
Arthritis Society)
m. Self-help or support
n. Phone help lines
o. Advice or guidance from
a physician or social
p. Counselling from a 1 Yes ÿ
physician or psychologist
IF no services used, go to Q.22.
IF services used: Now, I would like to ask a question about the cost of these services:
Thinking of all of these services, how much do you or the family pay per month in out-of-
pocket expenses?
Are you or your family contributing to any additional costs of care (for example, paying for
parking at doctors and hospitals, home adaptations, special diets)?
If YES ask: How much does this cost in total per month? $ ______________
Now I would like you to think about services or assistance you or ( ) are not currently
receiving. Are there any services or other forms of assistance that would help you in
caring for ( )?
(Do not read al ternatives. Circle all that apply) Hospital or nursing home for respite care WORK SITUATION
Now I have some questions about your work situation.
Do you currently work for pay?
About how many hours a week do you work?
During the past year, did you have to take time off from work to care for
( )’s health problems?
If YES:
b1.
Approximately how many days were you absent due to these health
problems during the past year?
Aside from the days you missed, did caring for (________)’s health problems limit
your productivity at work during the last year?
If YES:
c1.
On how many days was your productivity limited during the past year?
By what percentage do you think that your productivity was reduced on
those days?
During the past year, did you have to take time off from work because of your own
health problems?
If YES:
d1.
Approximately how many days were you absent due to these health
problems during the past year?
Aside from the days that you missed, did your health problems limit your
productivity at work during the last year?
If YES:
e1.
How many days was your working capacity reduced during the past year?
By what percentage do you think that your working capacity was reduced?
Because of caring for ( ), have you: (READ ALL)
Declined a job advancement? (transfer or promotion) Needed to leave work for doctor's appointment pertaining to ( )? Been interrupted frequently by phone calls from or pertaining to ( )? If the caregiver is presently working for pay, Go to Q. 25 When did you last work?
Why did you stop working? (Circle answers they mention: do not read)
CAREGIVER’S HEALTH
Now, I would like to talk with you about your health and how you have been feeling.
In general, would you say your health is:
| (SHOW CARD #4) (circle one)
1 Excellent 2 Very Good 3 Good 4 Fair 5 Poor 7 R 8 DK The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much?
(circle one number on each line) | (SHOW CARD #5)
Activities
Moderate activities, such as moving
a table, pushing a vacuum cleaner,
bowling, or playing golf
Climbing several flights of stairs
27. During the PAST 4 WEEKS, have you had any of the following problems with your work or
other regular daily activities as a result of your physical health?
(Circle one number on each line)
Accomplished less than you would like
Were limited in the kind of work or other activities
you could do.
28. During the PAST 4 WEEKS, have you had any of the following problems with your work or
other regular activities as a result of any emotional problems (such as feeling depressed or
anxious)? (circle one number on each line)
Accomplished less than you would like
Didn't do work or other activities as carefully as
29. During the PAST 4 WEEKS, how much did PAIN interfere with your normal work
(including both work outside the home and housework)? | (SHOW CARD #6)
1 Not at all 2 A little bit 3 Moderately 4 Quite a bit 5 Extremely 7 R 8 DK 30. These questions are about how you feel and how things have been with you during the PAST
4 WEEKS. For each question, please give the one answer that comes closest to the way you
have been feeling. How much of the time during the PAST 4 WEEKS -
| (SHOW CARD #7)
a) Have you felt calm and
peaceful?
b) Did you have a lot of energy?
c) Have you felt downhearted
and blue?
31. DURING THE PAST 4 WEEKS, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
| (SHOW CARD #8)
32. Now I will read you a list of ways you might have felt IN THE PAST WEEK. As I read each
statement, please tell me how often you felt this way during the PAST WEEK: Rarely, Some
of the time, a Moderate amount of the time, or Most of the time. | (SHOW CARD #9)
0 Rarely or none of the time (for less than 1 day in past week)1 Some or a little of the time (1-2 days)2 Occasionally or a moderate amount of the time (3-4 days)3 Most or all of the time (5-7 days)7 R During the past week
Occasionally
a) I was bothered by things that don't usually bother
b) I had trouble keeping my mind on what I was
c) I felt depressed
d) I felt that everything I did was an effort
e) I felt hopeful about the future
f) I felt fearful
g) My sleep was restless
h) I was happy
i) I felt lonely
j) I could not get going
33. Many people report that they experience positive or rewarding aspects of caregiving. I would
like you to think about any enjoyable or positive features you find in being a caregiver.
Do you find any positive aspects of caregiving?
If YES:
33a.
Could you briefly tell me what some of these are?
34. Finally I would like to ask about your income. What you tell me is confidential information.
Think about your household income from all sources (for example, jobs, social security).
Which category does your income fall into? | (SHOW CARD #10)
1 G 2 G 3 G 4 G 5 G 6 G 7 G 8 G 9 G 10 G 11 G 12 G 35. In order to complete the health service utilization component of our study, we would very
much appreciate your consent to access your Provincial health plan records. Please
remember, all information will be confidential as described on the consent form.
(Present Caregiver with the copy of the consent form to access their provincial health records.)
Consent given for Caregiver’s own records:
Conclusion
This is the end of the interview. Thank you very much for your help and your
patience. This completes your participation in the Canadian Study of Health and
Aging. We are very grateful for your assistance.
@ Interview End Time: ______ : ______ (Please use 24 hr clock) Housing arrangements of subject
1 Detached
Place of interview
This questionnaire, (items number 25-31), includes the SF-12 Health Survey, reproduced withpermission of Health Assessment Lab. Copyright 1994 ADL/IAD L Summary Informa tion Sheet
(to be filled out by interviewer after Caregiver/Informant Interview and passed on to clinician before clinical exam) Does the subject have difficulty with this activity?
ADL/IADL activity
(Difficulty includes ‘needs some help’ as well as
‘completely unable to do’)
Getting to places out of walking distance INTERVIEWER SUMMARY OF CAMDEX
Part I: Questions concerning recent history
Personality (238-244) 238 Personality
Memory (247-251)
General Intellectual functioning (254 - PFQ2)
Paranoid Traits (286 - 287)
Clouding / delirium (271 - 274)
Depressive symptoms (275 - 276)
Sleep (283)
Cerebrovascular problems (288 - 290)
General Summary (292)
Part II: Past History
A) Illnesses
(Questions 295 - 302,
B) Lifestyle habits (303 - 307)
Cognitive losses/problems
(318 - 319)
Other comments:

Source: http://csha.ca/media/file_downloads/CSHA%203%20-%20Caregiver%20Interview%20.pdf