Introduction: The pre-session questionnaires is a combination of choice and free text to get you thinking about the topics. When completing questionnaires be sure to submit your responses AND mark the page as complete. All questionnaires are also provided in the documents for download so that you can use these valuable organizing tools again later.
Session 1 Pre-Questionnaire has 12 questions and is the longest questionnaire in our course. This questionnaire allows us to get to know your identity as a person beyond your role as a patient or caregiver.
Questionnaire for session 1 allows us to get to know you as a person, beyond being a patient or caregiver.
Questionnaire Summary
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Question 1 of 11
1. Question
I describe myself as:
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Put your choice at the top.
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Interdependent with a network of support when needed.
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Interdependent, living with a spouse or friend.
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Dependent, I need or am providing support to either a spouse or child.
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Independent, no living children or spouse.
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Question 2 of 11
2. Question
I am most concerned about
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Being a burden to my family.
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Finding support needed.
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Planning ahead.
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Understanding my opinions regarding life-support measures.
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Communicating with family and support.
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Keeping faith and my beliefs as a central focus.
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Recognizing financial decisions.
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Question 3 of 11
3. Question
When and where during your day do you feel the best? The worst?
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This response will be reviewed and graded after submission.
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Question 4 of 11
4. Question
What do you find yourself thinking about most?
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This response will be reviewed and graded after submission.
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Question 5 of 11
5. Question
What are you most proud of/ What do you like about yourself?
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This response will be reviewed and graded after submission.
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Question 6 of 11
6. Question
How long have you been either a patient or caregiver?
List in years from 0-7+ years. -
Question 7 of 11
7. Question
What do you want for your future?
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This response will be reviewed and graded after submission.
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Question 8 of 11
8. Question
What are your fears?
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This response will be reviewed and graded after submission.
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Question 9 of 11
9. Question
Can you or your loved one talk candidly about health choices?
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This response will be reviewed and graded after submission.
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Question 10 of 11
10. Question
Does your circle of support, including your clinical team support your decision?
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Question 11 of 11
11. Question
How do you know?
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This response will be reviewed and graded after submission.
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