Caring for the Caregiver

Please choose an answer to continue.

To which Race/Ethnicity do you identify:

African American/Black
American Indian/Alaska Native
Asian American
Caucasian/White
Hispanic/Latino
Native Hawaiian/ Other Pacific Islander
India/Pakistan/ Bangledesh
Other (please specify)

Please choose an answer to continue.

To which gender do you identify:

Male
Female

Please choose an answer to continue.

In general, how would you rate your overall health?

Excellent
Very Good
Good
Fair
Poor

Please choose an answer to continue.

Have you smoked at least 100 cigarettes in your entire life? (Note: 5 packs = 100 cigarettes)

Yes
No
Don't Know

Please choose an answer to continue.

Do you now smoke cigarettes every day, some days, or not at all?

Every day
Some days
Not at all
I only smoke cigarettes in social situations only (at bars, parties, with friends, etc.)

Please choose an answer to continue.

Do you use other forms of tobacco? (select all that apply):

I use chewing tobacco.
I use e-cigarettes.
I smoke from a hookah/pipe.
I use a nicotine patch and/or nicotine lozenges.
I do not use other forms of tobacco.

Please choose an answer to continue.

Do you have a personal history of (select all that apply):

Please choose an answer to continue.

Do you have a family history of (select all that apply):

High blood pressure
High cholesterol
Heart disease
Stroke
Diabetes (high blood sugar)
Sudden death at a young age (45 years of age or younger)
Early heart attack (45 years of age or younger)
I do not know my family history.
I have no family history of any of these conditions.

Please choose an answer to continue.

How many minutes of moderate and/or high physical activity do you usually get per week? Examples of moderate physical activity include: walking briskly, gardening, water aerobics, or tennis (doubles). Examples of high physical activity include: jogging, swimming, biking, fitness classes like kickboxing and Zumba.

less than 30 minutes
30-60 minutes
61-90 minutes
91-149 minutes
150 minutes or more

Please choose an answer to continue.

How many servings of fruits and vegetables do you eat daily? (one serving = 1 cup fresh, 1 cup cooked, 1 medium size fruit)

One or less
2 daily
3 daily
4 daily
5 daily
6-8 daily
9 or more daily

Please choose an answer to continue.

How many servings of sweets do you eat a day (i.e.: 1 serving = 3 small cookies, 1 small piece of cake, 1 candy bar, 1 doughnut)?

One or less
Two daily
Three daily
Four daily
Five or more daily

Please choose an answer to continue.

How many servings of sugary beverages do you drink a day (i.e.: 1 serving= 12 oz. (1 can) of soda, 8 oz. of sports/energy drinks, 8 oz. iced tea, 8 oz. fruit drinks, 12 oz. mochas, 12 oz. frappuccinos)?

One or less
Two daily
Three daily
Four daily
Five or more daily

Please choose an answer to continue.

How often do you have a drink containing alcohol? (1 drink = 1 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor)

Never
Monthly or less
Two to four times per month
Two to three times per week
Four or more times per week

Please choose an answer to continue.

How many drinks containing alcohol do you have on a typical day when you are drinking? (1 drink = 1 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor)

1-2 drinks
3-4 drinks
5-6 drinks
7-9 drinks
10+ drinks
I never drink alcohol.

Please choose an answer to continue.

How much caffeine do you consume on a daily basis (1 drink = 8 oz. of coffee, 8 oz. of tea, 1 oz. of espresso, 8 oz. of specialty drink (i.e. mocha, latte), 12 oz. of soda, 8 oz. of energy drink, 2 oz. of 5 hour energy drink, 1 cup of chocolate)?

1-2 drinks
3-4 drinks
5-6 drinks
>6 drinks
I never drink caffeine.

Please choose an answer to continue.

How much water do you consume on a daily basis (1 cup = 8 oz.)?

1-2 cups
3-4 cups
5-6 cups
7-9 cups
10+ cups
I never drink water.

Please choose an answer to continue.

How many hours of sleep do you usually get per night?

less than 4 hours
4 hours
5 hours
6 hours
7 hours or more

Please choose an answer to continue.

I am sure that I will do what is best to lead a healthy life.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I believe that exercise and being active will help me to feel better about myself.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I am certain that I will make healthy food choices.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I know how to deal with things that bother me in a healthy way.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I believe that I can reach the goals that I set for myself.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I am sure that I can handle my problems well.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I believe that I can be more active.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I am sure that I will do what is best to keep myself healthy.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I am sure that I can spend less time watching TV.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I know that I can make healthy snack choices regularly.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I can deal with pressure from other people in positive ways.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I know what to do when things bother or upset me.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I believe that my family and friends will help me to reach my goals.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I am sure that I will feel better about myself if I exercise regularly.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I believe that being active is fun.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

I am able to talk to my family and friends about things that bother or upset me.

Strongly Disagree
Disagree
Neither Agree Nor Disagree
Agree
Strongly Agree

Please choose an answer to continue.

In the last month, how often have you felt that you were unable to control the important things in your life?

Never
Almost Never
Sometimes
Fairly Often
Very Often

Please choose an answer to continue.

In the last month, how often have you felt that you were unable to handle your personal problems?

Never
Almost Never
Sometimes
Fairly Often
Very Often

Please choose an answer to continue.

In the last month, how often have you felt that things were going your way?

Never
Almost Never
Sometimes
Fairly Often
Very Often

Please choose an answer to continue.

In the last month, how often have you felt that difficulties were piling up so high that you could not overcome them?

Never
Almost Never
Sometimes
Fairly Often
Very Often

Please choose an answer to continue.

Will you commit to working on improving at least one healthy lifestyle behavior today that can help to prevent heart disease?

Yes
No
Maybe

Please choose an answer to continue.

What healthy lifestyle behavior(s) will you work on improving? (select all that apply)

Please choose an answer to continue.

Are you between the ages of 18-40?

Yes
No

Please choose an answer to continue.

Do you have diabetes?

Yes
No

Please choose an answer to continue.

Do you have high blood pressure?

Yes
No

Please choose an answer to continue.

Have you smoked a cigarette or used any form of tobacco in the last 30 days?

Yes
No

Please choose an answer to continue.

Have you ever had a close family member (parent, sibling, grandparent, aunt/uncle) die of heart disease at an early age (younger than 45)?

Yes
No

Please choose an answer to continue.

Do you have a body mass index greater than 30? (please use available device to calculate)

Yes
No

Please answer all required fields to continue.

You spend your life caring for those around you.

Take the Survey

It takes most people around 10 minutes.

To which Race/Ethnicity do you identify:

To which gender do you identify:

In general, how would you rate your overall health?

Have you smoked at least 100 cigarettes in your entire life? (Note: 5 packs = 100 cigarettes)

Do you now smoke cigarettes every day, some days, or not at all?

Do you use other forms of tobacco? (select all that apply):

Do you have a personal history of (select all that apply):

Do you have a family history of (select all that apply):

How many servings of fruits and vegetables do you eat daily? (one serving = 1 cup fresh, 1 cup cooked, 1 medium size fruit)

How many servings of sweets do you eat a day (i.e.: 1 serving = 3 small cookies, 1 small piece of cake, 1 candy bar, 1 doughnut)?

How many servings of sugary beverages do you drink a day (i.e.: 1 serving= 12 oz. (1 can) of soda, 8 oz. of sports/energy drinks, 8 oz. iced tea, 8 oz. fruit drinks, 12 oz. mochas, 12 oz. frappuccinos)?

How often do you have a drink containing alcohol? (1 drink = 1 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor)

How many drinks containing alcohol do you have on a typical day when you are drinking? (1 drink = 1 12 oz. beer, 5 oz. wine, or 1.5 oz. liquor)

How much caffeine do you consume on a daily basis (1 drink = 8 oz. of coffee, 8 oz. of tea, 1 oz. of espresso, 8 oz. of specialty drink (i.e. mocha, latte), 12 oz. of soda, 8 oz. of energy drink, 2 oz. of 5 hour energy drink, 1 cup of chocolate)?

How much water do you consume on a daily basis (1 cup = 8 oz.)?

How many hours of sleep do you usually get per night?

I am sure that I will do what is best to lead a healthy life.

I believe that exercise and being active will help me to feel better about myself.

I am certain that I will make healthy food choices.

I know how to deal with things that bother me in a healthy way.

I believe that I can reach the goals that I set for myself.

I am sure that I can handle my problems well.

I believe that I can be more active.

I am sure that I will do what is best to keep myself healthy.

I am sure that I can spend less time watching TV.

I know that I can make healthy snack choices regularly.

I can deal with pressure from other people in positive ways.

I know what to do when things bother or upset me.

I believe that my family and friends will help me to reach my goals.

I am sure that I will feel better about myself if I exercise regularly.

I believe that being active is fun.

I am able to talk to my family and friends about things that bother or upset me.

In the last month, how often have you felt that you were unable to control the important things in your life?

In the last month, how often have you felt that you were unable to handle your personal problems?

In the last month, how often have you felt that things were going your way?

In the last month, how often have you felt that difficulties were piling up so high that you could not overcome them?

Will you commit to working on improving at least one healthy lifestyle behavior today that can help to prevent heart disease?

What healthy lifestyle behavior(s) will you work on improving? (select all that apply)

Are you between the ages of 18-40?

Do you have diabetes?

Do you have high blood pressure?

Have you smoked a cigarette or used any form of tobacco in the last 30 days?

Have you ever had a close family member (parent, sibling, grandparent, aunt/uncle) die of heart disease at an early age (younger than 45)?

Do you have a body mass index greater than 30? (please use available device to calculate)

Thank You!

Get Your Free Screening

Meet With Your Manager

Meet Your Care Partner

View This Week's Journal Starter

You spend your life caring
for those around you.

View This Week's
Journal Starter