Carers Survey

Carers survey

By taking part in this survey it helps us identify our carers which in turn will enable us to offer support and share information with you. Your personal details will be used to update your medical record to record you as a carer. Thank you.

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* 1. 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 best we can support you as a carer, both now and in the future.

Please tell us your age by ticking the box at the side of the age ranges

Under 18

18-24

25-30

31-40

41-50

51-64

65-74

75 and over

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* 2. More about you, please tick any 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 specify)

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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

Carers Survey

Carers survey

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* 2. More about you, please tick any that apply

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* 3. Whilst being a carer have you ever

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* 4. Please let us know about any other suggestions you feel may help you as a carer.

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* 5. In order for us to ensure you are recorded as a carer, if you are happy to, please leave your name and date of birth.