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Chronic Illnesses Survey

The information in this survey is being used by a writer for research on a book she is writing. If you are interested in being interviewed (via e-mail) to provide further information, please e-mail the writer at chalkbrd@hoosierlink.net or include your e-mail address in the final question.

The book will be a Christian inspirational resource for people struggling with chronic pain/illness issues. Names are optional.

By completing this survey, you are giving permission for this information to be used anonymously in the author's writing. If you have any questions, please feel free to ask.

Thank you for your participation.
Name (optional): 


  1. Indicate your gender:
    Female
    Male


  1. Indicate your connection(s) with a chronic illness (mark all that apply):
    I have a chronic illness.
    I have a spouse with a chronic illness.
    I have a child with a chronic illness.
    I have a parent with a chronic illness.
    I have a relative (other than the above) with a chronic illness.
    I have a friend with a chronic illness.


  1. Indicate the illness(es) (Mark all that apply.):
    AIDS/HIV
    Cancer
    Crohn's Disease
    Cystic Fibrosis
    Epilepsy
    Fibromyalgia
    Gulf War Syndrome
    Irritable Bowel Syndrome
    Lupus
    Lyme Disease
    Parkinson's
    Rheumatoid Arthritis
    Other


  1. If you checked other, please specify:


  1. Is the person with the illness a Christian?
    Yes
    No


  1. If you are NOT the person with the illness, are you a Christian?
    Yes
    No


  1. Indicate the age group of the person with the chronic illness: 


  1. How long has the person with the illness had it? 


  1. Has the person with the illness changed working conditions because of the illness?
    no change
    some reduced hours/activities
    changed to part-time
    severely reduced hours
    had to quit job


  1. Has the person with the illness experienced losses in any of the following areas? (Mark all that apply.)
    job
    spouse
    friends
    church involvement
    community involvement
    involvement in their child's activities
    dating
    other social interactions


  1. If you checked other, please specify.


  1. Has the person with the illness felt depressed during the illness?
    never
    rarely
    sometimes
    often
    always


  1. If you indicated that the person with the illness does experience depression, please indicate more specifically how often.
    several times a day
    once a day
    2-3 times a week
    once a week
    2-3 times a month
    a few times a year
    once a year
    once every few years


  1. Does the person with the illness feel frustrated at the limitations on their life because of the illness?
    yes
    maybe
    no


  1. If you indicated that the person with the illness does feel frustrated about their limitations, please indicate more specifically how often.
    several times a day
    once a day
    2-3 times a week
    once a week
    2-3 times a month
    a few times a year
    once a year
    once every few years


  1. Has the person with the chronic illness ever gone to a chiropractor for relief of their symptoms?
    Yes
    No


  1. If you answered yes to the person visiting a chiropractor for relief of symptoms, rank the amount of relief from symptoms the person with the chronic illness felt from those visits.

    1 = no relief from symptoms

    5 = very much relief from symptoms
    1 2 3 4 5



  1. What are the biggest PHYSICAL challenges the person with the illness faces because of their illness?


  1. What are the biggest EMOTIONAL challenges the person with the illness faces because of their illness?


  1. What are the biggest SPIRITUAL challenges the person with the illness faces because of their illness?


  1. How does the illness affect this person’s relationships?


  1. If you are NOT the person with the illness, are you put in a care-giver position because of this person’s illness?


  1. If you are not the person with the illness, has this person’s illness had an affect on your life? If so, in what way?


  1. If the person with the illness is a Christian, in what way is their faith affected by their illness?


  1. If the person with the illness is a Christian, in what way does their faith affect how they deal with their illness?


  1. If you are a care-giver for the person with the illness, in what way has this illness affected your spiritual life?


  1. What do you see as the biggest struggle for a person who has a chronic illness?


  1. Is there anything more you want to say about having a chronic illness or being affected by someone else's chronic illness?