Exit this survey MHNM 1719 CAREGIVERS 1. Question Title 1. Please complete the contact information below. First and Last Name: * Company: Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: * Phone Number: * Question Title 2. What is your age ? Question Title 3. What is your Gender ? Question Title 4. Do you personally provide care to someone who has had a stroke ? Yes No Question Title 5. What is your relationship to the patient under your care ? Spouse Daughter /Son Parent Sibling Other relative Friend Professional Caretaker Home Nurse Nursing Home Long term care facility None Other (please specify) Question Title 6. How long ago did patient experience their stoke ? Less than 6 months ago 6-12 months ago 12-18 months ago 18-24 months ago 24-36 months ago More than 36 months ago Next
