Mended Hearts/Mended Little Hearts Caregiver Survey
RequiredRequired Question(s)

In order to best meet the needs of caregivers, Mended Hearts and Mended Little Hearts need information about caregivers of patients with heart disease, including congenital heart defects. If you are a caregiver of a heart patient, please fill out the survey below. It should not take more than 15 minutes of your time.  All responses are anonymous unless you give us your name in the survey.  Thank you.

 
Required 1.
Gender
Male
Female
Required 2.
Age
30 years old or younger
31-40
41-50
51-60
61-70
71-80
Over 80 years old
Required 3.
How many years have you served as a caregiver to a heart patient?
Less than 1 year
1-5 years
6-10 years
11-15 years
More than 15 years
Required 4.
Are you caring for an adult patient?
Yes
No
Required 5.
Are you caring for a pediatric patient?
Yes
No
Required 6.
How would you describe your physical health?
Excellent
Good
Average
Somewhat Below Average
Poor
  • Comment:

  • 500 characters left.
Required 7.
How would you describe your mental health?
Excellent
Good
Average
Somewhat Below Average
Poor
  • Comment:

  • 500 characters left.
Required 8.
How would you describe your level of stress?
Extremely high
High
Average
Below average
Almost none
  • Comment:

  • 500 characters left.
Required 9.
Complete the following statement, "I seek medical care for myself..." (check all that apply)
At my regular annual check-ups
At occasional check-ups
When I don't feel well
Only when I absolutely have to
  • Comment:

  • 500 characters left.
Required 10.
How would you describe your eating habits?
I eat a healthy diet with lots of fruits and vegetables.
I eat a somewhat healthy diet, but I could eat more fruits and vegetables.
I eat when I can grab something, but I try to grab healthy foods.
I eat whatever is easiest, but it is not always healthy food.
I do not eat a healthy diet.
  • Comment:

  • 500 characters left.
Required 11.
How much time a day do you spend taking care of yourself or relaxing?
None
Under 10 minutes
11-15 minutes
16-30 minutes
30-60 minutes
1-2 hours
More than 2 hours
12.
Please rate the following items as to how helpful you feel they would be to you as a caregiver.  If you aren't sure, please leave that item blank.  If there are additional items/resources you find helpful, please add those in the comments section of this question.
 Not Helpful Somewhat helpful Helpful Very helpful Extremely helpful 
A printed booklet of caregiver tips and information
Helpful tips sent directly to your mobile device as text messages
Helpful tips sent directly to you as email messages
An online forum/community with other caregivers where you can write messages back and forth
Educational information about heart disease
Information about resources for caregivers.
  • Comment:

  • 500 characters left.
13.
Please write any other feedback for the Caregiver Committee here.
 

350 characters left.
14.

Optional Information (please write this information in the space below if you wish to share it.  It will ONLY be used by the Caregiver Committee unless we expressly ask you for additional information.): 

Name

Chapter Number/Group Name

Email address

Phone number

 

350 characters left.
15.
Would you like to be includeded in further Caregiver Committee updates by email?  (If the answer to this question is "yes," we need your email address in the previous question.)
Yes
No
Required 16.
Are you a member of Mended Hearts and/or Mended Little Hearts?
Yes
No

If you have any questions, please call 1-888-HEART99 (1-888-432-7899) or email info@mendedhearts.org.

 

Thank you for your time and assistance!