Resource Utilization Questionnaire: About You

                Your First Name:                 Your Last Name:         

                Patient's First Name:            Patient's Last Name:  


                Question Please select from the following options:
                What is your age?
                What is your Gender?
                What is your relationship to the patient?
                Number of children currently living with you:
                Do you live with the patient?
                How many other caregivers are invovled in the care?
                Among all caregivers what is your level of contribution?

              Work Status:

                Do you currently work for pay?

              IF NOWhy did you stop/reduce working?

                Other (please explain):

              IF YES
              Question Please select from the following options:
              1. How many hours do you work in total for pay per week?
              2. Of this number of hours, how many hours per week are you paid to care for the patient?
              3. During the last 30 days, by how many hours have you cut down on the number of hours that you usually work each week because of your caregiving responsibilities?
              4. During the lat 30 days, please specify the number of times that your caregiver responsibilities affected your work in the following ways:
                   a. Missed a whole day of work:
                  b. Missed a part of a day at work:

              HEALTH CARE

              1. During the last 30 days, how many times were you admitted in a hospital (for more than 24 hours)?

              2. If you were admitted in a hospital during the last 30 days, please specify the total number of nights spent in each type of ward.

              Ward Number of nights during the last 30 Days
              Internal Medicine
              General Ward

              3. During the last 30 days, how many times did you recieve care in a hospital emergency room (for less than 24 hours)?

              4. During the last 30 days, consider how many times you visitied a doctor, physiotherapist, psychologist or other health care professional. Please specify the number of visits for each type of care recieved.

                I did NOT visit any of these health care professionals during the last 30 days

              Type of Care Number of visits during the last 30 Days
              General practitioner
              Occupational therapist
              Social worker


              5. Please specify what mediations you are currently taking (prescription or over-the-counter).

                I am NOT taking any medications currently

              Name of Medication mgs Number of times per day Number of days taken in the last 30 days