Caregiver Experience Survey
Family caregivers are the backbone of healthcare, providing billions of hours of unpaid care annually. Yet their own needs often go unaddressed. This Caregiver Experience Survey compassionately checks in on caregiver wellbeing, measures stress levels and burnout risk, identifies specific support needs, and helps healthcare organizations connect caregivers with appropriate resources. The form uses gentle, supportive language and includes conditional logic to show relevant resources based on responses.
Try the Form
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export function caregiverFeedbackSurvey(form: FormTs) {
// Caregiver Experience Survey - Compassionate wellbeing check-in for family caregivers
// Demonstrates: EmojiRating, Slider, MatrixQuestion, CheckboxList, conditional support resources
// ============================================
// STATE
// ============================================
const stressLevel = form.state<number>(5);
const needsSupport = form.state<boolean>(false);
// ============================================
// HEADER
// ============================================
form.addRow(row => {
row.addTextPanel('header', {
label: 'Caregiver Check-In',
computedValue: () => "Taking care of yourself matters too. Let us know how you're doing.",
customStyles: {
background: 'linear-gradient(135deg, #a8edea 0%, #fed6e3 100%)',
color: '#1e293b',
padding: '28px',
borderRadius: '12px',
textAlign: 'center'
}
});
});
// ============================================
// SECTION 1: Care Situation
// ============================================
const situationSection = form.addSubform('situation', {
title: 'Your Care Situation'
});
situationSection.addRow(row => {
row.addDropdown('relationship', {
label: 'What is your relationship to the person you care for?',
options: [
{ id: 'spouse', name: 'Spouse/Partner' },
{ id: 'parent', name: 'Parent' },
{ id: 'child', name: 'Child' },
{ id: 'sibling', name: 'Sibling' },
{ id: 'grandparent', name: 'Grandparent' },
{ id: 'friend', name: 'Friend' },
{ id: 'other', name: 'Other family/relationship' }
],
placeholder: 'Select relationship...'
}, '1fr');
row.addDropdown('duration', {
label: 'How long have you been caregiving?',
options: [
{ id: 'new', name: 'Less than 1 month' },
{ id: 'months', name: '1-6 months' },
{ id: 'year', name: '6-12 months' },
{ id: 'years', name: '1-3 years' },
{ id: 'long', name: 'More than 3 years' }
],
placeholder: 'Select duration...'
}, '1fr');
});
situationSection.addRow(row => {
row.addCheckboxList('careTypes', {
label: 'What types of care do you provide? (Select all that apply)',
options: [
{ id: 'daily', name: 'Daily living activities (bathing, dressing, meals)' },
{ id: 'medical', name: 'Medical tasks (medications, treatments)' },
{ id: 'transport', name: 'Transportation to appointments' },
{ id: 'emotional', name: 'Emotional support and companionship' },
{ id: 'financial', name: 'Managing finances and bills' },
{ id: 'coordination', name: 'Coordinating care with providers' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 2: Current Wellbeing
// ============================================
const wellbeingSection = form.addSubform('wellbeing', {
title: 'How Are You Feeling?'
});
wellbeingSection.addRow(row => {
row.addEmojiRating('mood', {
label: 'How would you describe your overall mood lately?',
preset: 'mood',
size: 'lg',
showLabels: true,
alignment: 'center'
});
});
wellbeingSection.addRow(row => {
row.addSlider('stressLevel', {
label: 'Rate your current stress level',
min: 1,
max: 10,
step: 1,
defaultValue: 5,
showValue: true,
unit: '/ 10',
onValueChange: (val) => {
stressLevel.set(val ?? 5);
needsSupport.set((val ?? 5) >= 7);
}
});
});
wellbeingSection.addRow(row => {
row.addTextPanel('stressLabel', {
computedValue: () => {
const level = stressLevel();
if (level <= 3) return '💚 Manageable - Keep it up!';
if (level <= 6) return '💛 Moderate - Some support might help';
if (level <= 8) return '🧡 High - Please reach out for help';
return '❤️ Very High - You deserve support right now';
},
customStyles: () => {
const level = stressLevel();
const baseStyles = { textAlign: 'center', padding: '8px', borderRadius: '8px', fontWeight: 'bold' };
if (level <= 3) return { ...baseStyles, backgroundColor: '#d1fae5', color: '#065f46' };
if (level <= 6) return { ...baseStyles, backgroundColor: '#fef3c7', color: '#92400e' };
return { ...baseStyles, backgroundColor: '#fee2e2', color: '#991b1b' };
}
});
});
wellbeingSection.addRow(row => {
row.addSlider('energyLevel', {
label: 'Rate your energy level this past week',
min: 1,
max: 10,
step: 1,
defaultValue: 5,
showValue: true,
unit: '/ 10'
});
});
// ============================================
// SECTION 3: Sleep & Self-Care
// ============================================
const selfCareSection = form.addSubform('selfCare', {
title: 'Taking Care of Yourself'
});
selfCareSection.addRow(row => {
row.addRadioButton('sleepQuality', {
label: 'How has your sleep been?',
options: [
{ id: 'great', name: 'Great - Getting enough rest' },
{ id: 'ok', name: 'OK - Some disruptions' },
{ id: 'poor', name: 'Poor - Often interrupted or insufficient' },
{ id: 'very_poor', name: 'Very poor - Barely sleeping' }
],
orientation: 'vertical'
});
});
selfCareSection.addRow(row => {
row.addCheckboxList('selfCareActivities', {
label: 'In the past week, have you been able to:',
options: [
{ id: 'meals', name: 'Eat regular, nutritious meals' },
{ id: 'exercise', name: 'Get some physical activity' },
{ id: 'social', name: 'Connect with friends or family' },
{ id: 'hobbies', name: 'Do something enjoyable for yourself' },
{ id: 'breaks', name: 'Take short breaks from caregiving' },
{ id: 'appointments', name: 'Attend your own health appointments' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 4: Support Needs Assessment
// ============================================
const supportSection = form.addSubform('supportNeeds', {
title: 'Support You Need'
});
supportSection.addRow(row => {
row.addMatrixQuestion('supportMatrix', {
label: 'Rate how much you need the following types of support:',
rows: [
{ id: 'respite', label: 'Respite care (time off from caregiving)' },
{ id: 'info', label: 'Information about care needs' },
{ id: 'training', label: 'Training on care tasks' },
{ id: 'emotional', label: 'Emotional support/counseling' },
{ id: 'financial', label: 'Financial assistance' },
{ id: 'community', label: 'Community resources/services' }
],
columns: [
{ id: 'none', label: 'Not needed' },
{ id: 'low', label: 'Slightly' },
{ id: 'moderate', label: 'Moderately' },
{ id: 'high', label: 'Greatly' }
],
striped: true,
fullWidth: true
});
});
// ============================================
// SECTION 5: Healthcare Provider Support
// ============================================
const providerSection = form.addSubform('provider', {
title: 'Support from Healthcare Team'
});
providerSection.addRow(row => {
row.addStarRating('providerCommunication', {
label: "Rate the healthcare team's communication with you as a caregiver",
maxStars: 5,
size: 'lg',
alignment: 'center'
});
});
providerSection.addRow(row => {
row.addCheckboxList('providerNeeds', {
label: 'What would help you work better with the healthcare team?',
options: [
{ id: 'included', name: 'Being included in care discussions' },
{ id: 'explained', name: 'Having things explained clearly' },
{ id: 'written', name: 'Written care instructions' },
{ id: 'contact', name: 'Easy way to contact the care team' },
{ id: 'training', name: 'Training on home care tasks' },
{ id: 'acknowledgment', name: 'Recognition of my role as caregiver' }
],
orientation: 'vertical'
});
});
// ============================================
// SECTION 6: Crisis Support Resources (Conditional)
// ============================================
const crisisSection = form.addSubform('crisis', {
title: 'Support Resources for You',
isVisible: () => needsSupport(),
customStyles: {
backgroundColor: '#fef3c7',
padding: '20px',
borderRadius: '12px',
border: '2px solid #f59e0b'
}
});
crisisSection.addRow(row => {
row.addTextPanel('crisisMessage', {
label: "We're Here for You",
computedValue: () => "Your wellbeing matters. High stress is common among caregivers, and help is available.\n\nConsider reaching out to:\n• Your care coordinator or social worker\n• A caregiver support group\n• A mental health professional\n• The Caregiver Action Network: 1-855-227-3640",
customStyles: {
whiteSpace: 'pre-line',
fontSize: '14px',
lineHeight: '1.6'
}
});
});
crisisSection.addRow(row => {
row.addCheckbox('wantsFollowup', {
label: "I'd like someone to reach out to me about support options"
});
});
crisisSection.addRow(row => {
row.addTextbox('preferredContact', {
label: 'Best way to reach you:',
placeholder: 'Phone or email...',
isVisible: () => crisisSection.checkbox('wantsFollowup')?.value() === true
});
});
// ============================================
// SECTION 7: Open Feedback
// ============================================
const feedbackSection = form.addSubform('feedback', {
title: 'Additional Thoughts'
});
feedbackSection.addRow(row => {
row.addTextarea('challenges', {
label: 'What is your biggest challenge as a caregiver right now?',
placeholder: 'Share whatever is on your mind...',
rows: 3,
autoExpand: true
});
});
feedbackSection.addRow(row => {
row.addTextarea('whatHelps', {
label: 'What helps you cope with caregiving responsibilities?',
placeholder: 'What strategies, people, or resources support you?',
rows: 2,
autoExpand: true
});
});
// ============================================
// SUMMARY SECTION
// ============================================
const summarySection = form.addSubform('summary', {
title: 'Your Check-In Summary'
});
summarySection.addRow(row => {
row.addTextPanel('summaryContent', {
computedValue: () => {
const stress = stressLevel();
const energy = wellbeingSection.slider('energyLevel')?.value() ?? 5;
const mood = wellbeingSection.emojiRating('mood')?.value();
const sleep = selfCareSection.radioButton('sleepQuality')?.value();
const providerRating = providerSection.starRating('providerCommunication')?.value();
const moodLabels: Record<string, string> = {
'sad': 'Struggling',
'down': 'Discouraged',
'neutral': 'Managing',
'happy': 'Positive',
'excited': 'Thriving'
};
let summary = `Caregiver Wellbeing Summary\n${'═'.repeat(30)}\n\n`;
if (mood) {
summary += `Mood: ${moodLabels[mood] || mood}\n`;
}
summary += `Stress Level: ${stress}/10\n`;
summary += `Energy Level: ${energy}/10\n`;
if (sleep) {
const sleepLabels: Record<string, string> = {
'great': 'Good',
'ok': 'Fair',
'poor': 'Poor',
'very_poor': 'Very Poor'
};
summary += `Sleep: ${sleepLabels[sleep]}\n`;
}
if (providerRating) {
summary += `\nProvider Support: ${'★'.repeat(providerRating)}${'☆'.repeat(5 - providerRating)}\n`;
}
// Wellbeing indicator
const wellbeingScore = (10 - stress + energy) / 2;
summary += '\n';
if (wellbeingScore >= 7) {
summary += '💚 Overall Status: Doing well';
} else if (wellbeingScore >= 4) {
summary += '💛 Overall Status: Some support may help';
} else {
summary += '❤️ Overall Status: Please seek support';
}
return summary;
},
customStyles: () => {
const stress = stressLevel();
const energy = wellbeingSection.slider('energyLevel')?.value() ?? 5;
const wellbeingScore = (10 - stress + energy) / 2;
const baseStyles = {
padding: '16px',
borderRadius: '8px',
whiteSpace: 'pre-wrap',
fontFamily: 'monospace',
fontSize: '13px'
};
if (wellbeingScore >= 7) {
return { ...baseStyles, backgroundColor: '#d1fae5', borderLeft: '4px solid #10b981' };
} else if (wellbeingScore >= 4) {
return { ...baseStyles, backgroundColor: '#fef3c7', borderLeft: '4px solid #f59e0b' };
}
return { ...baseStyles, backgroundColor: '#fee2e2', borderLeft: '4px solid #ef4444' };
}
});
});
// ============================================
// FORM CONFIGURATION
// ============================================
form.configureSubmitButton({
label: 'Submit Check-In'
});
form.configureCompletionScreen({
type: 'text',
title: 'Thank You for Sharing',
message: "Your wellbeing matters as much as the person you care for. Remember: you can't pour from an empty cup. We appreciate your dedication and hope you'll reach out for support when you need it."
});
}
Frequently Asked Questions
Who should receive this survey?
Any family member or friend who provides care for a patient - helping with daily activities, medical tasks, transportation, or emotional support. This includes spouses, adult children, parents of ill children, and other informal caregivers.
How often should caregivers complete this survey?
Monthly check-ins are recommended for ongoing care situations. During care transitions (hospital discharge, new diagnosis, hospice) more frequent check-ins may be appropriate. Avoid survey fatigue by keeping it brief.
What if a caregiver shows signs of burnout?
The survey includes conditional sections that appear when stress levels are high. These offer support resources and can trigger follow-up from care coordinators. The summary helps identify at-risk caregivers quickly.
Is this survey HIPAA compliant?
The template focuses on caregiver wellbeing, not patient health information. However, always consult with your compliance team and ensure your form deployment method meets healthcare data security requirements.
Can caregivers complete this anonymously?
You can configure the form to be anonymous, though this limits your ability to provide personalized follow-up. Consider optional identification so caregivers can choose their comfort level.
How can this data improve caregiver support programs?
Aggregate data reveals common challenges (respite needs, information gaps, financial stress) to guide program development. Individual responses help care coordinators provide targeted support to struggling caregivers.