Edridge Road: Carers Questionnaire

DO YOU LOOK AFTER SOMEONE WHO CAN’T GET BY WITHOUT YOUR HELP?

If you are an unpaid carer who provides care and support to a partner, relative, friend or neighbour who wouldn’t be able to get by on their own, we’d really appreciate your answers to the questions below. Your answers will tell us how we can best support you as a carer, both now and in the future.

Question Title

* 1. Please tell us your age by ticking the box at the side of the age ranges below

Under 18 years old

18-24 years

25-30 years

31-40 years

41-50 years

51-64 years

65-74 years

75 years and over

Prefer not to say

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* 2. In addition to being a carer, are you:
(Please tick all that apply)

At school

At college/university

Employed (full or part-time, including self-employed)

Retired from paid work

Unable to work due to long-term sickness

Looking after home/family

Other (please give details below)

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* 3. Whilst being a carer have you ever:

Felt that your caring role has made you ill

Injured yourself when lifting or moving someone

Felt stressed, anxious or depressed (or anything similar)

Put off seeing your GP because you didn’t have time

Not taken medical treatment you should have taken

Had to stop paid work so you could continue caring

Felt isolated or lonely

Felt it hard to leave somebody so you could attend an appointment

Found it difficult to take the person you care for to the GP practice

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* 4. How else can we help you?
Please use the box on the right to suggest anything we could do to help you as a carer

Many thanks for taking the time to complete this questionnaire.

IMORTANT

If you haven’t already let us know that you’re a carer, please mention it to a member of staff at the practice so that we can make a note of it on your medical records. With your permission, we can also refer you to your local carers service for information, advice and support.

If you or the person you care for is urgently in need of support, please ask us to refer you to social services or call them directly without delay.

Did you know that our surgery has a Carers Champion and hosts regular ‘Carers Coffee Mornings’? Please speak with reception for details of the next event.

Question Title

* 1. Please tell us your age by ticking the box at the side of the age ranges below

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* 2. In addition to being a carer, are you:(Please tick all that apply)

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* 3. Whilst being a carer have you ever:

Question Title

* 4. How else can we help you?Please use the box on the right to suggest anything we could do to help you as a carer

* 2. In addition to being a carer, are you:
(Please tick all that apply)

* 4. How else can we help you?
Please use the box on the right to suggest anything we could do to help you as a carer