- Indicate your gender:
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- Indicate your connection(s) with a chronic illness (mark all that apply):
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- Indicate the illness(es) (Mark all that apply.):
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- If you checked other, please specify:
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- Is the person with the illness a Christian?
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- If you are NOT the person with the illness, are you a Christian?
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- Indicate the age group of the person with the chronic illness:
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- How long has the person with the illness had it?
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- Has the person with the illness changed working conditions because of the illness?
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- Has the person with the illness experienced losses in any of the following areas? (Mark all that apply.)
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- If you checked other, please specify.
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- Has the person with the illness felt depressed during the illness?
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- If you indicated that the person with the illness does experience depression, please indicate more specifically how often.
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- Does the person with the illness feel frustrated at the limitations on their life because of the illness?
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- If you indicated that the person with the illness does feel frustrated about their limitations, please indicate more specifically how often.
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- Has the person with the chronic illness ever gone to a chiropractor for relief of their symptoms?
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- 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
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- What are the biggest PHYSICAL challenges the person with the illness faces because of their illness?
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- What are the biggest EMOTIONAL challenges the person with the illness faces because of their illness?
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- What are the biggest SPIRITUAL challenges the person with the illness faces because of their illness?
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- How does the illness affect this person’s relationships?
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- If you are NOT the person with the illness, are you put in a care-giver position because of this person’s illness?
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- 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?
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- If the person with the illness is a Christian, in what way is their faith affected by their illness?
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- If the person with the illness is a Christian, in what way does their faith affect how they deal with their illness?
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- If you are a care-giver for the person with the illness, in what way has this illness affected your spiritual life?
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- What do you see as the biggest struggle for a person who has a chronic illness?
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- Is there anything more you want to say about having a chronic illness or being affected by someone else's chronic illness?
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