{"id":27,"date":"2020-08-21T05:43:37","date_gmt":"2020-08-21T05:43:37","guid":{"rendered":"https:\/\/communityforcaregivers.com\/assessments\/?page_id=27"},"modified":"2021-03-28T02:45:08","modified_gmt":"2021-03-28T02:45:08","slug":"caregiver-health-and-wellness-checkup-complete","status":"publish","type":"page","link":"https:\/\/communityforcaregivers.com\/checkup\/caregiver-health-and-wellness-checkup-complete\/","title":{"rendered":"Caregiver Health Complete Check-up"},"content":{"rendered":"\r\n<style type=\"text\/css\">\r\n@import url('https:\/\/fonts.googleapis.com\/css?family=Lato');\r\n\r\n\r\nbody #wpforms-51 {\r\n\t\tpadding:30px ;border-width:.5px ;border-color:#54aab7 ;border-radius:11px ;-web-border-radius:11px ;-moz-border-radius:11px ;\r\n\t\t\tfont-family:Lato;border-style: solid;}\r\n\r\n\t\r\n\r\n\r\n\tbody #wpforms-51 .wpforms-head-container .wpforms-description {\r\n\t\tline-height:24px ;font-size:18px;\t\tdisplay:block;\r\n\t}\r\n\r\n\r\n\tbody #wpforms-51 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input[type=email],\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field input[type=tel],\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field input[type=url],\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field input[type=password],\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field input[type=number]{\r\n\t\t\tfont-size:16px ;\t\t\t\t\t} \r\n\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field .wpforms-field-row{\r\n\t\t\t\t\t}\r\n\tbody #wpforms-51 .wpforms-form .wpforms-field select{\r\n\t\tfont-size:16px ;\t\t\t\t}\r\n\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field-radio li label,\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field-payment-multiple li label{\r\n\t\t\tfont-size:16px ;\t\t}\r\n\tbody #wpforms-51 .wpforms-form .wpforms-field-checkbox li label {\r\n\t\tfont-size:16px ;\t}       \r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field label.wpforms-field-label,\r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field .wpforms-field-label{\r\n\t\tfont-size:16px ;line-height:20px;\t\t}       \r\n\t\tbody #wpforms-51 .wpforms-form .wpforms-field .wpforms-field-description {\r\n\t\tfont-size:16px ;\t\t}       \r\n\r\n}\r\n\/*Option to add custom CSS *\/\r\n\r\n\r\n\r\n\t\t<\/style>\r\n\t\t<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-51\"><form id=\"wpforms-form-51\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"51\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/checkup\/wp-json\/wp\/v2\/pages\/27\" data-token=\"4e16b68607abea1ddf5cfc0a8527c557\"><div class=\"wpforms-head-container\"><div class=\"wpforms-description\">This check-up is provided to help you monitor your life as a caregiver. You can use these answers to assess what areas you could improve on and as conversation starters with others to make changes and find help.<br\/><br\/>  \r\nPlease allow for 20-30 minutes to complete the assessment.<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#72b239\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> - <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 7<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:14.285714285714%;background-color:#72b239;\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-51-field_13-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"13\"><\/div><div id=\"wpforms-51-field_124-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"124\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_124\">Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-51-field_124\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][124]\" required><\/div><div id=\"wpforms-51-field_3-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_3\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-51-field_3\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-51-field_12-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"12\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"51\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" style=\"display:none;\"><div id=\"wpforms-51-field_4-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"4\"><h3 id=\"wpforms-51-field_4\" name=\"wpforms[fields][4]\">Caregiver Physical Health<\/h3><div class=\"wpforms-field-description\">This section of the assessment explores your physical health, including your diet, exercise, sleep, care for existing conditions, doctor visits, etc. <\/div><\/div><div id=\"wpforms-51-field_38-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"38\"><input type=\"hidden\" id=\"wpforms-51-field_38\" name=\"wpforms[fields][38]\" value=\".\"><\/div><div id=\"wpforms-51-field_8-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_8\">I consider the food choices I make overall to be\u2026<\/label><ul id=\"wpforms-51-field_8\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_8_1\" name=\"wpforms[fields][8]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_8_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_8_2\" name=\"wpforms[fields][8]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_8_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_8_3\" name=\"wpforms[fields][8]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_8_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_8_4\" name=\"wpforms[fields][8]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_8_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_8_5\" name=\"wpforms[fields][8]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_8_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_1-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_1\">I consider the amount of food I consume to be...<\/label><ul id=\"wpforms-51-field_1\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_1_1\" name=\"wpforms[fields][1]\" value=\"Less than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_1_1\">Less than I need<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_1_2\" name=\"wpforms[fields][1]\" value=\"Just what I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_1_2\">Just what I need<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_1_3\" name=\"wpforms[fields][1]\" value=\"More than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_1_3\">More than I need<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_9-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_9\"> In the past week, the degree to which my diet \/ eating has been negatively affected by my role as a caregiver is\u2026<\/label><ul id=\"wpforms-51-field_9\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_9_1\" name=\"wpforms[fields][9]\" value=\"Not at all\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_9_1\">Not at all<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_9_2\" name=\"wpforms[fields][9]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_9_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_9_3\" name=\"wpforms[fields][9]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_9_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_9_4\" name=\"wpforms[fields][9]\" value=\"Quite a bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_9_4\">Quite a bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_9_5\" name=\"wpforms[fields][9]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_9_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_10-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_10\">I consider the amount of activity I get each day to be\u2026<\/label><ul id=\"wpforms-51-field_10\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_10_1\" name=\"wpforms[fields][10]\" value=\"Less than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_10_1\">Less than I need<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_10_2\" name=\"wpforms[fields][10]\" value=\"Just what I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_10_2\">Just what I need<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_10_3\" name=\"wpforms[fields][10]\" value=\"More than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_10_3\">More than I need<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_11-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_11\">I exercise _____ days in an average week.<\/label><ul id=\"wpforms-51-field_11\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_11_1\" name=\"wpforms[fields][11]\" value=\"0\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_11_1\">0<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_11_7\" name=\"wpforms[fields][11]\" value=\"1 - 2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_11_7\">1 - 2<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_11_3\" name=\"wpforms[fields][11]\" value=\"3 - 4\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_11_3\">3 - 4<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_11_4\" name=\"wpforms[fields][11]\" value=\"5 - 6\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_11_4\">5 - 6<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_11_5\" name=\"wpforms[fields][11]\" value=\"7\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_11_5\">7<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_16-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_16\">In the past week, the degree to which my activity \/ exercise has been negatively affected by my role as a caregiver is... <\/label><ul id=\"wpforms-51-field_16\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_16_1\" name=\"wpforms[fields][16]\" value=\"Not at all\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_16_1\">Not at all<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_16_2\" name=\"wpforms[fields][16]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_16_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_16_3\" name=\"wpforms[fields][16]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_16_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_16_4\" name=\"wpforms[fields][16]\" value=\"Quite a bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_16_4\">Quite a bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_16_5\" name=\"wpforms[fields][16]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_16_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_17-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_17\">I consider my physical flexibility to be\u2026.<\/label><ul id=\"wpforms-51-field_17\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_17_1\" name=\"wpforms[fields][17]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_17_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_17_2\" name=\"wpforms[fields][17]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_17_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_17_3\" name=\"wpforms[fields][17]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_17_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_17_4\" name=\"wpforms[fields][17]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_17_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_17_5\" name=\"wpforms[fields][17]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_17_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_18-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_18\">I consider my weight-management to be\u2026<\/label><ul id=\"wpforms-51-field_18\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_18_1\" name=\"wpforms[fields][18]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_18_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_18_2\" name=\"wpforms[fields][18]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_18_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_18_3\" name=\"wpforms[fields][18]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_18_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_18_4\" name=\"wpforms[fields][18]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_18_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_18_5\" name=\"wpforms[fields][18]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_18_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_19-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_19\">I consider my mobility (ability to walk and move independently)  to be\u2026.<\/label><ul id=\"wpforms-51-field_19\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_19_1\" name=\"wpforms[fields][19]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_19_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_19_2\" name=\"wpforms[fields][19]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_19_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_19_3\" name=\"wpforms[fields][19]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_19_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_19_4\" name=\"wpforms[fields][19]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_19_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_19_5\" name=\"wpforms[fields][19]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_19_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_20-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_20\">Across one week, I average _____ hours of sleep  per night.<\/label><ul id=\"wpforms-51-field_20\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_20_1\" name=\"wpforms[fields][20]\" value=\"0 - 2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_20_1\">0 - 2<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_20_2\" name=\"wpforms[fields][20]\" value=\"2 - 4\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_20_2\">2 - 4<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_20_3\" name=\"wpforms[fields][20]\" value=\"4 - 6\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_20_3\">4 - 6<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_20_4\" name=\"wpforms[fields][20]\" value=\"6 - 8\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_20_4\">6 - 8<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_20_5\" name=\"wpforms[fields][20]\" value=\"8+\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_20_5\">8+<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_22-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_22\">On an average day, I report my average level of alertness\/sleepiness to be\u2026<\/label><ul id=\"wpforms-51-field_22\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_22_1\" name=\"wpforms[fields][22]\" value=\"Very sleepy\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_22_1\">Very sleepy<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_22_2\" name=\"wpforms[fields][22]\" value=\"Sleepy\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_22_2\">Sleepy<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_22_3\" name=\"wpforms[fields][22]\" value=\"Neither\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_22_3\">Neither<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_22_4\" name=\"wpforms[fields][22]\" value=\"Alert\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_22_4\">Alert<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_22_5\" name=\"wpforms[fields][22]\" value=\"Very Alert\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_22_5\">Very Alert<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_24-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_24\">In the past week, the degree to which my sleep has been negatively affected by my role as a caregiver is\u2026<\/label><ul id=\"wpforms-51-field_24\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_24_1\" name=\"wpforms[fields][24]\" value=\"Not at all\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_24_1\">Not at all<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_24_2\" name=\"wpforms[fields][24]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_24_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_24_3\" name=\"wpforms[fields][24]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_24_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_24_4\" name=\"wpforms[fields][24]\" value=\"Quite a bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_24_4\">Quite a bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_24_5\" name=\"wpforms[fields][24]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_24_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_25-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_25\">I take ______ (number) maintenance medications  (on a regular basis).<\/label><ul id=\"wpforms-51-field_25\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_25_1\" name=\"wpforms[fields][25]\" value=\"0\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_25_1\">0<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_25_2\" name=\"wpforms[fields][25]\" value=\"1\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_25_2\">1<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_25_3\" name=\"wpforms[fields][25]\" value=\"2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_25_3\">2<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_25_4\" name=\"wpforms[fields][25]\" value=\"3\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_25_4\">3<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_25_5\" name=\"wpforms[fields][25]\" value=\"4+\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_25_5\">4+<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_26-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_26\">My compliance with taking prescribed medication is...<\/label><ul id=\"wpforms-51-field_26\"><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_26_6\" name=\"wpforms[fields][26]\" value=\"N\/A\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_26_6\">N\/A<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_26_1\" name=\"wpforms[fields][26]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_26_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_26_2\" name=\"wpforms[fields][26]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_26_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_26_3\" name=\"wpforms[fields][26]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_26_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_26_4\" name=\"wpforms[fields][26]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_26_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_26_5\" name=\"wpforms[fields][26]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_26_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_28-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_28\">Regarding the treatment of any known diagnosed conditions, my self-care (not considering medication) is... <\/label><ul id=\"wpforms-51-field_28\"><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_28_6\" name=\"wpforms[fields][28]\" value=\"N\/A\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_28_6\">N\/A<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_28_1\" name=\"wpforms[fields][28]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_28_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_28_2\" name=\"wpforms[fields][28]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_28_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_28_3\" name=\"wpforms[fields][28]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_28_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_28_4\" name=\"wpforms[fields][28]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_28_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_28_5\" name=\"wpforms[fields][28]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_28_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_29-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_29\">Throughout an average week, what is the level (include a rating of frequency) of physical pain you experience? <\/label><ul id=\"wpforms-51-field_29\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_29_1\" name=\"wpforms[fields][29]\" value=\"No pain\/Very little pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_29_1\">No pain\/Very little pain<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_29_2\" name=\"wpforms[fields][29]\" value=\"Some pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_29_2\">Some pain<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_29_3\" name=\"wpforms[fields][29]\" value=\"Moderate pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_29_3\">Moderate pain<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_29_4\" name=\"wpforms[fields][29]\" value=\"Quite a bit of pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_29_4\">Quite a bit of pain<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_29_5\" name=\"wpforms[fields][29]\" value=\"Extreme pain\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_29_5\">Extreme pain<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_30-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_30\">My contact with physicians and other healthcare \/ fitness providers who monitor my physical health is\u2026<\/label><ul id=\"wpforms-51-field_30\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_30_1\" name=\"wpforms[fields][30]\" value=\"Less than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_30_1\">Less than I need<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_30_2\" name=\"wpforms[fields][30]\" value=\"Just what I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_30_2\">Just what I need<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_30_3\" name=\"wpforms[fields][30]\" value=\"More than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_30_3\">More than I need<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_31-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_31\">The importance I assign to my physical health is best described as... <\/label><ul id=\"wpforms-51-field_31\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_31_1\" name=\"wpforms[fields][31]\" value=\"Not important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_31_1\">Not important<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_31_2\" name=\"wpforms[fields][31]\" value=\"Somewhat important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_31_2\">Somewhat important<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_31_3\" name=\"wpforms[fields][31]\" value=\"Moderately important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_31_3\">Moderately important<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_31_4\" name=\"wpforms[fields][31]\" value=\"Quite important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_31_4\">Quite important<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_31_5\" name=\"wpforms[fields][31]\" value=\"Extremely important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_31_5\">Extremely important<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_32-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_32\">I consider my overall physical health to be... <\/label><ul id=\"wpforms-51-field_32\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_32_1\" name=\"wpforms[fields][32]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_32_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_32_2\" name=\"wpforms[fields][32]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_32_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_32_3\" name=\"wpforms[fields][32]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_32_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_32_4\" name=\"wpforms[fields][32]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_32_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_32_5\" name=\"wpforms[fields][32]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_32_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_34-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_34\">The degree to which my overall physical health has been negatively affected by my role as a caregiver is... <\/label><ul id=\"wpforms-51-field_34\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_34_1\" name=\"wpforms[fields][34]\" value=\"Not at all\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_34_1\">Not at all<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_34_2\" name=\"wpforms[fields][34]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_34_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_34_3\" name=\"wpforms[fields][34]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_34_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_34_4\" name=\"wpforms[fields][34]\" value=\"Quite a bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_34_4\">Quite a bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_34_5\" name=\"wpforms[fields][34]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_34_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_35-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"35\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_35\">My attention to and plan for the future of my physical health is...<\/label><ul id=\"wpforms-51-field_35\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_35_1\" name=\"wpforms[fields][35]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_35_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_35_2\" name=\"wpforms[fields][35]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_35_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_35_3\" name=\"wpforms[fields][35]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_35_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_35_4\" name=\"wpforms[fields][35]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_35_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_35_5\" name=\"wpforms[fields][35]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_35_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_36-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"36\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"51\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" style=\"display:none;\"><div id=\"wpforms-51-field_37-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"37\"><h3 id=\"wpforms-51-field_37\" name=\"wpforms[fields][37]\">Caregiver Mental and Emotional Health<\/h3><div class=\"wpforms-field-description\">This section of the assessment explores your mental and emotional health, including questions that examine stress, guilt, respite, depression, resilience, coping skills, spiritual practices, etc.<\/div><\/div><div id=\"wpforms-51-field_39-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"39\"><input type=\"hidden\" id=\"wpforms-51-field_39\" name=\"wpforms[fields][39]\" value=\".\"><\/div><div id=\"wpforms-51-field_40-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"40\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_40\">How much time do you take for respite (include any type of personal time for rest (other than nighttime sleep), relief, recovery, recreation, meditation)?<\/label><ul id=\"wpforms-51-field_40\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_40_1\" name=\"wpforms[fields][40]\" value=\"Less than 2 hours\/week\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_40_1\">Less than 2 hours\/week<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_40_2\" name=\"wpforms[fields][40]\" value=\"2 - 5 hours\/week\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_40_2\">2 - 5 hours\/week<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_40_3\" name=\"wpforms[fields][40]\" value=\"5 - 10 hours\/week\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_40_3\">5 - 10 hours\/week<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_40_4\" name=\"wpforms[fields][40]\" value=\"10 - 15 hours\/week\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_40_4\">10 - 15 hours\/week<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_40_5\" name=\"wpforms[fields][40]\" value=\"15+ hours\/week\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_40_5\">15+ hours\/week<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_41-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_41\">How would you describe your life\u2019s current stress level?  <\/label><ul id=\"wpforms-51-field_41\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_41_1\" name=\"wpforms[fields][41]\" value=\"Not at all Stressful\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_41_1\">Not at all Stressful<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_41_2\" name=\"wpforms[fields][41]\" value=\"Somewhat Stressful\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_41_2\">Somewhat Stressful<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_41_3\" name=\"wpforms[fields][41]\" value=\"Moderately Stressful\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_41_3\">Moderately Stressful<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_41_4\" name=\"wpforms[fields][41]\" value=\"Quite Stressful\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_41_4\">Quite Stressful<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_41_5\" name=\"wpforms[fields][41]\" value=\"Extremely Stressful\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_41_5\">Extremely Stressful<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_42-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_42\">During the past week have you felt completely overwhelmed? <\/label><ul id=\"wpforms-51-field_42\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_42_1\" name=\"wpforms[fields][42]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_42_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_42_2\" name=\"wpforms[fields][42]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_42_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_43-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_43\">During the past week have you had a crying spell?<\/label><ul id=\"wpforms-51-field_43\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_43_1\" name=\"wpforms[fields][43]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_43_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_43_2\" name=\"wpforms[fields][43]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_43_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_44-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_44\">Describe the level of irritation, anger, or resentment you feel.<\/label><ul id=\"wpforms-51-field_44\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_44_1\" name=\"wpforms[fields][44]\" value=\"Not at all Angry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_44_1\">Not at all Angry<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_44_2\" name=\"wpforms[fields][44]\" value=\"Somewhat \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_44_2\">Somewhat <\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_44_3\" name=\"wpforms[fields][44]\" value=\"Moderately \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_44_3\">Moderately <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_44_4\" name=\"wpforms[fields][44]\" value=\"Quite \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_44_4\">Quite <\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_44_5\" name=\"wpforms[fields][44]\" value=\"Extremely Angry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_44_5\">Extremely Angry<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_45-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"45\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_45\">Describe the level of sadness\/depression you experience (this includes feelings of hopelessness\/worthlessness).<\/label><ul id=\"wpforms-51-field_45\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_45_1\" name=\"wpforms[fields][45]\" value=\"Not at all Sad\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_45_1\">Not at all Sad<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_45_2\" name=\"wpforms[fields][45]\" value=\"Somewhat \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_45_2\">Somewhat <\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_45_3\" name=\"wpforms[fields][45]\" value=\"Moderately \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_45_3\">Moderately <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_45_4\" name=\"wpforms[fields][45]\" value=\"Quite \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_45_4\">Quite <\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_45_5\" name=\"wpforms[fields][45]\" value=\"Extremely Sad\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_45_5\">Extremely Sad<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_46-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_46\">How much worry\/anxiety do you feel for the caregiving situation you are in (including worry\/anxiety about the person receiving your care)?<\/label><ul id=\"wpforms-51-field_46\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_46_1\" name=\"wpforms[fields][46]\" value=\"No\/Very Little Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_46_1\">No\/Very Little Worry<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_46_2\" name=\"wpforms[fields][46]\" value=\"Some Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_46_2\">Some Worry<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_46_3\" name=\"wpforms[fields][46]\" value=\"Moderate Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_46_3\">Moderate Worry<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_46_4\" name=\"wpforms[fields][46]\" value=\"Quite a bit of Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_46_4\">Quite a bit of Worry<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_46_5\" name=\"wpforms[fields][46]\" value=\"Extreme Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_46_5\">Extreme Worry<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_47-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_47\">How much worry\/anxiety do you feel for your life as a whole (not just the caregiving situation you are in)?<\/label><ul id=\"wpforms-51-field_47\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_47_1\" name=\"wpforms[fields][47]\" value=\"No\/Very Little Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_47_1\">No\/Very Little Worry<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_47_2\" name=\"wpforms[fields][47]\" value=\"Some Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_47_2\">Some Worry<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_47_3\" name=\"wpforms[fields][47]\" value=\"Moderate Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_47_3\">Moderate Worry<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_47_4\" name=\"wpforms[fields][47]\" value=\"Quite a bit of Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_47_4\">Quite a bit of Worry<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_47_5\" name=\"wpforms[fields][47]\" value=\"Extreme Worry\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_47_5\">Extreme Worry<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_48-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_48\">Select the statement below that best describes the burden\/load you feel from your caregiving role.<\/label><ul id=\"wpforms-51-field_48\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_48_1\" name=\"wpforms[fields][48]\" value=\"I feel no or very little burden.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_48_1\">I feel no or very little burden.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_48_2\" name=\"wpforms[fields][48]\" value=\"I feel some burden, but it&#039;s quite manageable.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_48_2\">I feel some burden, but it's quite manageable.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_48_3\" name=\"wpforms[fields][48]\" value=\"I feel a moderate amount of burden, but if I work hard, I can achieve balance.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_48_3\">I feel a moderate amount of burden, but if I work hard, I can achieve balance.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_48_4\" name=\"wpforms[fields][48]\" value=\"I feel quite a bit of burden; therefore, other parts of my life are suffering.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_48_4\">I feel quite a bit of burden; therefore, other parts of my life are suffering.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_48_5\" name=\"wpforms[fields][48]\" value=\"I feel extremely burdened; I do not have a minute&#039;s break from caregiving responsibilities.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_48_5\">I feel extremely burdened; I do not have a minute's break from caregiving responsibilities.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_49-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"49\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_49\">What level of guilt, if any, do you feel in your caregiving role?<\/label><ul id=\"wpforms-51-field_49\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_49_1\" name=\"wpforms[fields][49]\" value=\"I have no to very little guilt about my caregiving responsibilities.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_49_1\">I have no to very little guilt about my caregiving responsibilities.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_49_2\" name=\"wpforms[fields][49]\" value=\"I feel some guilt, but it doesn\u2019t plague me.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_49_2\">I feel some guilt, but it doesn\u2019t plague me.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_49_3\" name=\"wpforms[fields][49]\" value=\"I feel a moderate amount of guilt, but I can manage\/cope with the feelings to find peace.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_49_3\">I feel a moderate amount of guilt, but I can manage\/cope with the feelings to find peace.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_49_4\" name=\"wpforms[fields][49]\" value=\"I feel quite a bit of guilt; it drives me to work too hard and worry too much.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_49_4\">I feel quite a bit of guilt; it drives me to work too hard and worry too much.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_49_5\" name=\"wpforms[fields][49]\" value=\"I feel an extreme amount of guilt, usually every day. It is destroying my feelings of self-worth.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_49_5\">I feel an extreme amount of guilt, usually every day. It is destroying my feelings of self-worth.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_50-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"50\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_50\">To what extent do you find meaning, satisfaction and purpose in life because of your caregiving role?<\/label><ul id=\"wpforms-51-field_50\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_50_1\" name=\"wpforms[fields][50]\" value=\"I find no or very little meaning, satisfaction, and purpose in life because of my caregiving role.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_50_1\">I find no or very little meaning, satisfaction, and purpose in life because of my caregiving role.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_50_2\" name=\"wpforms[fields][50]\" value=\"I find some meaning, satisfaction, and purpose in life because of my caregiving role.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_50_2\">I find some meaning, satisfaction, and purpose in life because of my caregiving role.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_50_3\" name=\"wpforms[fields][50]\" value=\"I find moderate meaning, satisfaction, and purpose in life because of my caregiving role.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_50_3\">I find moderate meaning, satisfaction, and purpose in life because of my caregiving role.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_50_4\" name=\"wpforms[fields][50]\" value=\"I find quite a bit of meaning, satisfaction, and purpose in life because of my caregiving role.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_50_4\">I find quite a bit of meaning, satisfaction, and purpose in life because of my caregiving role.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_50_5\" name=\"wpforms[fields][50]\" value=\"I find an extreme amount of meaning, satisfaction, and purpose in life because of my caregiving role.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_50_5\">I find an extreme amount of meaning, satisfaction, and purpose in life because of my caregiving role.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_51-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_51\">How has your ability to make decisions and stay focused been negatively affected by your role as a caregiver?<\/label><ul id=\"wpforms-51-field_51\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_51_1\" name=\"wpforms[fields][51]\" value=\"Not at All\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_51_1\">Not at All<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_51_2\" name=\"wpforms[fields][51]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_51_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_51_3\" name=\"wpforms[fields][51]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_51_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_51_4\" name=\"wpforms[fields][51]\" value=\"Quite a Bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_51_4\">Quite a Bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_51_5\" name=\"wpforms[fields][51]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_51_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_52-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"52\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_52\">How would you describe your ability and skills to cope and\/or manage your thoughts and feelings?<\/label><ul id=\"wpforms-51-field_52\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_52_1\" name=\"wpforms[fields][52]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_52_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_52_2\" name=\"wpforms[fields][52]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_52_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_52_3\" name=\"wpforms[fields][52]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_52_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_52_4\" name=\"wpforms[fields][52]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_52_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_52_5\" name=\"wpforms[fields][52]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_52_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_53-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"53\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_53\">How much does spirituality\/religion contribute to your current situation and life?<\/label><ul id=\"wpforms-51-field_53\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_53_1\" name=\"wpforms[fields][53]\" value=\"I do not affiliate with\/use any spiritual practice\/religious tradition.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_53_1\">I do not affiliate with\/use any spiritual practice\/religious tradition.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_53_2\" name=\"wpforms[fields][53]\" value=\"Spiritual\/religious practice plays a small role in my life.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_53_2\">Spiritual\/religious practice plays a small role in my life.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_53_3\" name=\"wpforms[fields][53]\" value=\"Spiritual\/religious practice plays a moderate role in my life.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_53_3\">Spiritual\/religious practice plays a moderate role in my life.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_53_4\" name=\"wpforms[fields][53]\" value=\"Spiritual\/religious practice plays a significant role in my life.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_53_4\">Spiritual\/religious practice plays a significant role in my life.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_53_5\" name=\"wpforms[fields][53]\" value=\"Everything I do is grounded in and filtered through a lens of spiritual\/religious practice.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_53_5\">Everything I do is grounded in and filtered through a lens of spiritual\/religious practice.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_54-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_54\">My contact with mental\/emotional\/spiritual-health providers (such as therapists, psychologists and pastors) who monitor my emotional\/mental\/spiritual health is\u2026<\/label><ul id=\"wpforms-51-field_54\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_54_1\" name=\"wpforms[fields][54]\" value=\"Less than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_54_1\">Less than I need<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_54_2\" name=\"wpforms[fields][54]\" value=\"Just what I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_54_2\">Just what I need<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_54_3\" name=\"wpforms[fields][54]\" value=\"More than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_54_3\">More than I need<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_55-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_55\">The importance I assign to my mental\/emotional health is best described as:<\/label><ul id=\"wpforms-51-field_55\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_55_1\" name=\"wpforms[fields][55]\" value=\"Not Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_55_1\">Not Important<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_55_2\" name=\"wpforms[fields][55]\" value=\"Somewhat Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_55_2\">Somewhat Important<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_55_3\" name=\"wpforms[fields][55]\" value=\"Moderately Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_55_3\">Moderately Important<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_55_4\" name=\"wpforms[fields][55]\" value=\"Quite Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_55_4\">Quite Important<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_55_5\" name=\"wpforms[fields][55]\" value=\"Extremely Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_55_5\">Extremely Important<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_56-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"56\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_56\">I consider my overall mental\/emotional health to be\u2026<\/label><ul id=\"wpforms-51-field_56\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_56_1\" name=\"wpforms[fields][56]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_56_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_56_2\" name=\"wpforms[fields][56]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_56_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_56_3\" name=\"wpforms[fields][56]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_56_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_56_4\" name=\"wpforms[fields][56]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_56_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_56_5\" name=\"wpforms[fields][56]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_56_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_57-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_57\">The degree to which my overall mental\/emotional health has been negatively affected\/disrupted by my role as a caregiver is... <\/label><ul id=\"wpforms-51-field_57\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_57_1\" name=\"wpforms[fields][57]\" value=\"Not at All\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_57_1\">Not at All<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_57_2\" name=\"wpforms[fields][57]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_57_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_57_3\" name=\"wpforms[fields][57]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_57_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_57_4\" name=\"wpforms[fields][57]\" value=\"Quite a Bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_57_4\">Quite a Bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_57_5\" name=\"wpforms[fields][57]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_57_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_58-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"58\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_58\">My attention to and plan for the future of my mental\/emotional health is... <\/label><ul id=\"wpforms-51-field_58\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_58_1\" name=\"wpforms[fields][58]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_58_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_58_2\" name=\"wpforms[fields][58]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_58_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_58_3\" name=\"wpforms[fields][58]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_58_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_58_4\" name=\"wpforms[fields][58]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_58_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_58_5\" name=\"wpforms[fields][58]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_58_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_59-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"59\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"51\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" style=\"display:none;\"><div id=\"wpforms-51-field_60-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"60\"><h3 id=\"wpforms-51-field_60\" name=\"wpforms[fields][60]\">Caregiver Social and Family Health<\/h3><div class=\"wpforms-field-description\">This section of the assessment explores the health of your social interactions and family relationships.<\/div><\/div><div id=\"wpforms-51-field_77-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"77\"><input type=\"hidden\" id=\"wpforms-51-field_77\" name=\"wpforms[fields][77]\" value=\".\"><\/div><div id=\"wpforms-51-field_61-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"61\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_61\">How would you describe your level of loneliness\/isolation in your caregiving role?<\/label><ul id=\"wpforms-51-field_61\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_61_1\" name=\"wpforms[fields][61]\" value=\"Not at all Lonely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_61_1\">Not at all Lonely<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_61_2\" name=\"wpforms[fields][61]\" value=\"Somewhat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_61_2\">Somewhat<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_61_3\" name=\"wpforms[fields][61]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_61_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_61_4\" name=\"wpforms[fields][61]\" value=\"Quite a Bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_61_4\">Quite a Bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_61_5\" name=\"wpforms[fields][61]\" value=\"Extremely Lonely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_61_5\">Extremely Lonely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_62-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"62\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_62\">Describe your relationship with the recipient of your care.<\/label><ul id=\"wpforms-51-field_62\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_62_1\" name=\"wpforms[fields][62]\" value=\"Terrible--We constantly fight and bitterly disagree about decisions and issues.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_62_1\">Terrible--We constantly fight and bitterly disagree about decisions and issues.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_62_2\" name=\"wpforms[fields][62]\" value=\"Poor--We are not close, we disagree, but it is not constant\/bitter.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_62_2\">Poor--We are not close, we disagree, but it is not constant\/bitter.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_62_3\" name=\"wpforms[fields][62]\" value=\"Fair--We make it work, but it\u2019s neither warm nor cold. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_62_3\">Fair--We make it work, but it\u2019s neither warm nor cold. <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_62_4\" name=\"wpforms[fields][62]\" value=\"Good--We are mostly aligned and work well together, but it\u2019s not overly warm.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_62_4\">Good--We are mostly aligned and work well together, but it\u2019s not overly warm.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_62_5\" name=\"wpforms[fields][62]\" value=\"Excellent--The relationship is incredibly warm and loving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_62_5\">Excellent--The relationship is incredibly warm and loving, we are almost always aligned.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_63-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_63\">Realizing that individual relationships can vary widely, what is the \u201caverage level\u201d relationship you have with other family members who ARE directly engaged in the caregiving situation.<\/label><ul id=\"wpforms-51-field_63\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_63_1\" name=\"wpforms[fields][63]\" value=\"Terrible--We constantly fight and bitterly disagree about decisions and issues.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_63_1\">Terrible--We constantly fight and bitterly disagree about decisions and issues.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_63_2\" name=\"wpforms[fields][63]\" value=\"Poor--We are not close, we disagree, but it is not constant\/bitter.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_63_2\">Poor--We are not close, we disagree, but it is not constant\/bitter.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_63_3\" name=\"wpforms[fields][63]\" value=\"Fair--We make it work, but it\u2019s neither warm nor cold. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_63_3\">Fair--We make it work, but it\u2019s neither warm nor cold. <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_63_4\" name=\"wpforms[fields][63]\" value=\"Good--We are mostly aligned and work well together, but it\u2019s not overly warm.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_63_4\">Good--We are mostly aligned and work well together, but it\u2019s not overly warm.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_63_5\" name=\"wpforms[fields][63]\" value=\"Excellent--The relationship is incredibly warm and loving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_63_5\">Excellent--The relationship is incredibly warm and loving, we are almost always aligned.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_63_6\" name=\"wpforms[fields][63]\" value=\"N\/A - No other family members are directly engaged in this caregiving situation.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_63_6\">N\/A - No other family members are directly engaged in this caregiving situation.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_64-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_64\">What is the \u201caverage level\u201d relationship you have with family members who are NOT directly engaged in the caregiving situation.<\/label><ul id=\"wpforms-51-field_64\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_64_1\" name=\"wpforms[fields][64]\" value=\"Terrible--We constantly fight and bitterly disagree about decisions and issues.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_64_1\">Terrible--We constantly fight and bitterly disagree about decisions and issues.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_64_2\" name=\"wpforms[fields][64]\" value=\"Poor--We are not close, we disagree, but it is not constant\/bitter.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_64_2\">Poor--We are not close, we disagree, but it is not constant\/bitter.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_64_3\" name=\"wpforms[fields][64]\" value=\"Fair--We make it work, but it\u2019s neither warm nor cold. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_64_3\">Fair--We make it work, but it\u2019s neither warm nor cold. <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_64_4\" name=\"wpforms[fields][64]\" value=\"Good--We are mostly aligned and work well together, but it\u2019s not overly warm.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_64_4\">Good--We are mostly aligned and work well together, but it\u2019s not overly warm.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_64_5\" name=\"wpforms[fields][64]\" value=\"Excellent--The relationship is incredibly warm and loving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_64_5\">Excellent--The relationship is incredibly warm and loving, we are almost always aligned.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_64_6\" name=\"wpforms[fields][64]\" value=\"N\/A - No other family members are directly engaged in this caregiving situation.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_64_6\">N\/A - No other family members are directly engaged in this caregiving situation.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_65-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_65\">What is the quality of your current relationship with your significant other\/spouse\/partner.<\/label><ul id=\"wpforms-51-field_65\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_65_1\" name=\"wpforms[fields][65]\" value=\"Terrible--We constantly fight and bitterly disagree about decisions and issues.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_65_1\">Terrible--We constantly fight and bitterly disagree about decisions and issues.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_65_2\" name=\"wpforms[fields][65]\" value=\"Poor--We are not close, we disagree, but it is not constant\/bitter.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_65_2\">Poor--We are not close, we disagree, but it is not constant\/bitter.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_65_3\" name=\"wpforms[fields][65]\" value=\"Fair--We make it work, but it\u2019s neither warm nor cold. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_65_3\">Fair--We make it work, but it\u2019s neither warm nor cold. <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_65_4\" name=\"wpforms[fields][65]\" value=\"Good--We are mostly aligned and work well together, but it\u2019s not overly warm.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_65_4\">Good--We are mostly aligned and work well together, but it\u2019s not overly warm.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_65_5\" name=\"wpforms[fields][65]\" value=\"Excellent--The relationship is incredibly warm and loving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_65_5\">Excellent--The relationship is incredibly warm and loving, we are almost always aligned.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_65_6\" name=\"wpforms[fields][65]\" value=\"N\/A - No significant other\/spouse\/partner.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_65_6\">N\/A - No significant other\/spouse\/partner.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_66-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"66\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_66\">If you have children, what is your \u201caverage level\u201d of relationship with them as a group?<\/label><ul id=\"wpforms-51-field_66\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_66_1\" name=\"wpforms[fields][66]\" value=\"Terrible--We constantly fight and bitterly disagree about decisions and issues.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_66_1\">Terrible--We constantly fight and bitterly disagree about decisions and issues.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_66_2\" name=\"wpforms[fields][66]\" value=\"Poor--We are not close, we disagree, but it is not constant\/bitter.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_66_2\">Poor--We are not close, we disagree, but it is not constant\/bitter.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_66_3\" name=\"wpforms[fields][66]\" value=\"Fair--We make it work, but it\u2019s neither warm nor cold. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_66_3\">Fair--We make it work, but it\u2019s neither warm nor cold. <\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_66_4\" name=\"wpforms[fields][66]\" value=\"Good--We are mostly aligned and work well together, but it\u2019s not overly warm.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_66_4\">Good--We are mostly aligned and work well together, but it\u2019s not overly warm.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_66_5\" name=\"wpforms[fields][66]\" value=\"Excellent--The relationship is incredibly warm and loving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_66_5\">Excellent--The relationship is incredibly warm and loving, we are almost always aligned.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_66_6\" name=\"wpforms[fields][66]\" value=\"N\/A - No children.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_66_6\">N\/A - No children.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_67-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_67\">If you work, part-time or full-time, what is your level of social interaction with work colleagues?<\/label><ul id=\"wpforms-51-field_67\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_67_1\" name=\"wpforms[fields][67]\" value=\"No - Very little social engagement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_67_1\">No - Very little social engagement<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_67_2\" name=\"wpforms[fields][67]\" value=\"Some social engagement \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_67_2\">Some social engagement <\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_67_3\" name=\"wpforms[fields][67]\" value=\"Moderate social engagement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_67_3\">Moderate social engagement<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_67_4\" name=\"wpforms[fields][67]\" value=\"Quite a bit of social engagement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_67_4\">Quite a bit of social engagement<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_67_5\" name=\"wpforms[fields][67]\" value=\"Extreme amount of social engagementving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_67_5\">Extreme amount of social engagementving, we are almost always aligned.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_67_6\" name=\"wpforms[fields][67]\" value=\"N\/A - I do not work nor do I have work colleagues\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_67_6\">N\/A - I do not work nor do I have work colleagues<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_68-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_68\">Consider other communities\/groups you are part of (religious, neighborhood, dinner groups, community causes, etc.), What is your level of social interaction with these communities?<\/label><ul id=\"wpforms-51-field_68\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_68_1\" name=\"wpforms[fields][68]\" value=\"No - Very little social engagement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_68_1\">No - Very little social engagement<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_68_2\" name=\"wpforms[fields][68]\" value=\"Some social engagement \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_68_2\">Some social engagement <\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_68_3\" name=\"wpforms[fields][68]\" value=\"Moderate social engagement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_68_3\">Moderate social engagement<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_68_4\" name=\"wpforms[fields][68]\" value=\"Quite a bit of social engagement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_68_4\">Quite a bit of social engagement<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_68_5\" name=\"wpforms[fields][68]\" value=\"Extreme amount of social engagementving, we are almost always aligned.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_68_5\">Extreme amount of social engagementving, we are almost always aligned.<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_68_6\" name=\"wpforms[fields][68]\" value=\"N\/A - I do not have relationships with any of these kinds of groups\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_68_6\">N\/A - I do not have relationships with any of these kinds of groups<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_69-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_69\">Considering your total level of social interactions across all groups, what amount of social interaction do you have? <\/label><ul id=\"wpforms-51-field_69\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_69_1\" name=\"wpforms[fields][69]\" value=\"Less than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_69_1\">Less than I need<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_69_2\" name=\"wpforms[fields][69]\" value=\"Just what I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_69_2\">Just what I need<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_69_3\" name=\"wpforms[fields][69]\" value=\"More than I need\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_69_3\">More than I need<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_70-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"70\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_70\">The importance I assign to my social and family health is best described as\u2026<\/label><ul id=\"wpforms-51-field_70\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_70_1\" name=\"wpforms[fields][70]\" value=\"Not Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_70_1\">Not Important<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_70_2\" name=\"wpforms[fields][70]\" value=\"Somewhat Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_70_2\">Somewhat Important<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_70_3\" name=\"wpforms[fields][70]\" value=\"Moderately Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_70_3\">Moderately Important<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_70_4\" name=\"wpforms[fields][70]\" value=\"Quite Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_70_4\">Quite Important<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_70_5\" name=\"wpforms[fields][70]\" value=\"Extremely Important\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_70_5\">Extremely Important<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_71-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_71\">I consider my overall social interactions\/health to be\u2026<\/label><ul id=\"wpforms-51-field_71\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_71_1\" name=\"wpforms[fields][71]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_71_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_71_2\" name=\"wpforms[fields][71]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_71_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_71_3\" name=\"wpforms[fields][71]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_71_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_71_4\" name=\"wpforms[fields][71]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_71_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_71_5\" name=\"wpforms[fields][71]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_71_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_72-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_72\">The degree to which my overall social interactions\/health has been negatively affected\/disrupted by my role as a caregiver is\u2026<\/label><ul id=\"wpforms-51-field_72\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_72_1\" name=\"wpforms[fields][72]\" value=\"Not at All\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_72_1\">Not at All<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_72_2\" name=\"wpforms[fields][72]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_72_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_72_3\" name=\"wpforms[fields][72]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_72_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_72_4\" name=\"wpforms[fields][72]\" value=\"Quite a Bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_72_4\">Quite a Bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_72_5\" name=\"wpforms[fields][72]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_72_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_73-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_73\">My attention to and plan for the future of my social interactions\/health is...<\/label><ul id=\"wpforms-51-field_73\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_73_1\" name=\"wpforms[fields][73]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_73_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_73_2\" name=\"wpforms[fields][73]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_73_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_73_3\" name=\"wpforms[fields][73]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_73_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_73_4\" name=\"wpforms[fields][73]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_73_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_73_5\" name=\"wpforms[fields][73]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_73_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_74-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"74\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"4\" data-formid=\"51\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" style=\"display:none;\"><div id=\"wpforms-51-field_75-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"75\"><h3 id=\"wpforms-51-field_75\" name=\"wpforms[fields][75]\">Caregiver Financial and Employment Health<\/h3><div class=\"wpforms-field-description\">This section of the assessment explores your financial\/employment health, including how much time is spent in your caregiving role.<\/div><\/div><div id=\"wpforms-51-field_76-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"76\"><input type=\"hidden\" id=\"wpforms-51-field_76\" name=\"wpforms[fields][76]\" value=\".\"><\/div><div id=\"wpforms-51-field_125-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"125\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_125\">What is the average number of hours per DAY you spend fulfilling caregiving responsibilities?<\/label><input type=\"text\" id=\"wpforms-51-field_125\" class=\"wpforms-field-small\" name=\"wpforms[fields][125]\" ><\/div><div id=\"wpforms-51-field_126-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"126\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_126\">What is the average number of hours per WEEK you spend fulfilling caregiving responsibilities?<\/label><input type=\"text\" id=\"wpforms-51-field_126\" class=\"wpforms-field-small\" name=\"wpforms[fields][126]\" ><\/div><div id=\"wpforms-51-field_80-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_80\">As objectively as you can, select which statement best describes the amount of time you spend as a caregiver:<\/label><ul id=\"wpforms-51-field_80\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_80_1\" name=\"wpforms[fields][80]\" value=\"I spend entirely too much time as a caregiver and my life is out of control because of it. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_80_1\">I spend entirely too much time as a caregiver and my life is out of control because of it. <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_80_2\" name=\"wpforms[fields][80]\" value=\"I spend more time than I likely need to spend as a caregiver and would like to reduce those hours.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_80_2\">I spend more time than I likely need to spend as a caregiver and would like to reduce those hours.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_80_3\" name=\"wpforms[fields][80]\" value=\"I think I spend just about the right amount of time as a caregiver--it\u2019s in balance and I am satisfied.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_80_3\">I think I spend just about the right amount of time as a caregiver--it\u2019s in balance and I am satisfied.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_80_4\" name=\"wpforms[fields][80]\" value=\"I should spend more time than I do as a caregiver and would like to increase those hours.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_80_4\">I should spend more time than I do as a caregiver and would like to increase those hours.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_80_5\" name=\"wpforms[fields][80]\" value=\"I spend entirely too little time as a caregiver--and have a strong desire to spend more time.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_80_5\">I spend entirely too little time as a caregiver--and have a strong desire to spend more time.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_127-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"127\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_127\">What is the average amount of money you spend per week because of your caregiving responsibilities?<\/label><input type=\"text\" id=\"wpforms-51-field_127\" class=\"wpforms-field-small\" name=\"wpforms[fields][127]\" placeholder=\"$\" ><\/div><div id=\"wpforms-51-field_82-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"82\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_82\">As objectively as you can, select which statement best describes the amount of money you spend on this caregiving situation:<\/label><ul id=\"wpforms-51-field_82\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_82_1\" name=\"wpforms[fields][82]\" value=\"I spend entirely too much money on this caregiving situation and my finances and financial future are in  great danger.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_82_1\">I spend entirely too much money on this caregiving situation and my finances and financial future are in  great danger.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_82_2\" name=\"wpforms[fields][82]\" value=\"I spend more money than I likely should be spending on this caregiving situation and would like to  reduce that spend.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_82_2\">I spend more money than I likely should be spending on this caregiving situation and would like to  reduce that spend.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_82_3\" name=\"wpforms[fields][82]\" value=\"I think I spend just about the right amount of money on this caregiving situation; I\u2019m satisfied.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_82_3\">I think I spend just about the right amount of money on this caregiving situation; I\u2019m satisfied.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_82_4\" name=\"wpforms[fields][82]\" value=\"I should spend more money on this caregiving situation than I do, and I\u2019d like to increase that spend.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_82_4\">I should spend more money on this caregiving situation than I do, and I\u2019d like to increase that spend.<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_82_5\" name=\"wpforms[fields][82]\" value=\"I spend entirely too little money on this caregiving situation and have a strong desire to spend more.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_82_5\">I spend entirely too little money on this caregiving situation and have a strong desire to spend more.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_83-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_83\">Choose the statement below that best characterizes how you think about your employment and your caregiving responsibilities: (Consider modifications to your employment environment\/location, hours worked, decisions about promotions, job changes, etc.)<\/label><ul id=\"wpforms-51-field_83\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_83_1\" name=\"wpforms[fields][83]\" value=\"I have made a few modifications to my employment because of my caregiving, but nothing drastic-my caregiving situation has affected 5-20% of my work life.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_83_1\">I have made a few modifications to my employment because of my caregiving, but nothing drastic-my caregiving situation has affected 5-20% of my work life.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_83_2\" name=\"wpforms[fields][83]\" value=\"I have made several changes to my employment situation--a few significant changes, because of my role as a caregiver. My caregiving situation has affected 25-50% of my work life.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_83_2\">I have made several changes to my employment situation--a few significant changes, because of my role as a caregiver. My caregiving situation has affected 25-50% of my work life.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_83_3\" name=\"wpforms[fields][83]\" value=\"I have made a lot of modifications to my employment situation (affecting 50-75% of my work life) because of my caregiving responsibilities. I\u2019ve chosen different hours, different positions, and different jobs--often at a sacrifice, to accommodate my caregiving responsibilities.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_83_3\">I have made a lot of modifications to my employment situation (affecting 50-75% of my work life) because of my caregiving responsibilities. I\u2019ve chosen different hours, different positions, and different jobs--often at a sacrifice, to accommodate my caregiving responsibilities.<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_83_4\" name=\"wpforms[fields][83]\" value=\"Everything about my employment situation would be different if it were not for my caregiving responsibilities--I have made tremendous sacrifices and tradeoffs to accommodate my caregiving (affecting 75-100% of my work life). I would work different hours, may not have quit\/modified my job, perhaps would work in a different industry with a different company, work in a different city--the trajectory of my career would look very different. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_83_4\">Everything about my employment situation would be different if it were not for my caregiving responsibilities--I have made tremendous sacrifices and tradeoffs to accommodate my caregiving (affecting 75-100% of my work life). I would work different hours, may not have quit\/modified my job, perhaps would work in a different industry with a different company, work in a different city--the trajectory of my career would look very different. <\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_84-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"84\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_84\">How willing are you to\/comfortable are you in talk(ing) with your employer about your caregiving situation?<\/label><ul id=\"wpforms-51-field_84\"><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_84_6\" name=\"wpforms[fields][84]\" value=\"N\/A - I do not have an employer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_84_6\">N\/A - I do not have an employer<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_84_1\" name=\"wpforms[fields][84]\" value=\"Not at all willing\/comfortable\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_84_1\">Not at all willing\/comfortable<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_84_2\" name=\"wpforms[fields][84]\" value=\"Somewhat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_84_2\">Somewhat<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_84_3\" name=\"wpforms[fields][84]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_84_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_84_4\" name=\"wpforms[fields][84]\" value=\"Quite\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_84_4\">Quite<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_84_5\" name=\"wpforms[fields][84]\" value=\"Extremely willing\/comfortable\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_84_5\">Extremely willing\/comfortable<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_85-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"85\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_85\">Which of the following people at work have you told about your caregiving situation? (Select all that apply)<\/label><ul id=\"wpforms-51-field_85\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_1\" name=\"wpforms[fields][85][]\" value=\"N\/A - I do not work\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_1\">N\/A - I do not work<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_2\" name=\"wpforms[fields][85][]\" value=\"My immediate supervisor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_2\">My immediate supervisor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_3\" name=\"wpforms[fields][85][]\" value=\"My direct reports\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_3\">My direct reports<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_4\" name=\"wpforms[fields][85][]\" value=\"Human resources\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_4\">Human resources<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_5\" name=\"wpforms[fields][85][]\" value=\"Other management\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_5\">Other management<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_6\" name=\"wpforms[fields][85][]\" value=\"Other co-workers\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_6\">Other co-workers<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_85_7\" name=\"wpforms[fields][85][]\" value=\"I have not told anyone at work about my caregiving situation\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_85_7\">I have not told anyone at work about my caregiving situation<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_86-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_86\">How supportive is your employer of your caregiving responsibilities?<\/label><ul id=\"wpforms-51-field_86\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_86_1\" name=\"wpforms[fields][86]\" value=\"N\/A - I do not have an employer\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_86_1\">N\/A - I do not have an employer<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_86_2\" name=\"wpforms[fields][86]\" value=\"Not at all\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_86_2\">Not at all<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_86_3\" name=\"wpforms[fields][86]\" value=\"Somewhat\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_86_3\">Somewhat<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_86_4\" name=\"wpforms[fields][86]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_86_4\">Moderately<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_86_5\" name=\"wpforms[fields][86]\" value=\"Quite\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_86_5\">Quite<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_86_6\" name=\"wpforms[fields][86]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_86_6\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_87-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"87\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_87\">What kinds of programs \/ accommodations does your employer provide for your caregiving role\/situation? (Select all that apply)<\/label><ul id=\"wpforms-51-field_87\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_1\" name=\"wpforms[fields][87][]\" value=\"N\/A - I am not employed\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_1\">N\/A - I am not employed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_2\" name=\"wpforms[fields][87][]\" value=\"None\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_2\">None<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_3\" name=\"wpforms[fields][87][]\" value=\"Leave of Absence program\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_3\">Leave of Absence program<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_4\" name=\"wpforms[fields][87][]\" value=\"FMLA (Family Medical Leave Act)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_4\">FMLA (Family Medical Leave Act)<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_5\" name=\"wpforms[fields][87][]\" value=\"Telecommuting or flexible working\/flextime accommodations\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_5\">Telecommuting or flexible working\/flextime accommodations<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_6\" name=\"wpforms[fields][87][]\" value=\"Caregiving resources (online, helpline, specific counseling)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_6\">Caregiving resources (online, helpline, specific counseling)<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_7\" name=\"wpforms[fields][87][]\" value=\"Employee wellness programs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_7\">Employee wellness programs<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_8\" name=\"wpforms[fields][87][]\" value=\"Employee assistance\/education programs (EAP)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_8\">Employee assistance\/education programs (EAP)<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_9\" name=\"wpforms[fields][87][]\" value=\"Mental health \/ counseling services\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_9\">Mental health \/ counseling services<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-51-field_87_10\" name=\"wpforms[fields][87][]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_87_10\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_88-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_88\">Have you experienced adverse employment action as a result of your caregiving duties? <\/label><ul id=\"wpforms-51-field_88\"><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_88_4\" name=\"wpforms[fields][88]\" value=\"N\/A - I am not employed\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_88_4\">N\/A - I am not employed<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_88_2\" name=\"wpforms[fields][88]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_88_2\">No<\/label><\/li><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_88_1\" name=\"wpforms[fields][88]\" value=\"Yes - Describe the adverse action in the following text box.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_88_1\">Yes - Describe the adverse action in the following text box.<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_89-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"89\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-51-field_89\">Adverse employment action: <\/label><input type=\"text\" id=\"wpforms-51-field_89\" class=\"wpforms-field-large\" name=\"wpforms[fields][89]\" placeholder=\"If yes, describe the adverse action here.\" ><\/div><div id=\"wpforms-51-field_90-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"90\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_90\">The degree to which my overall financial\/employment condition\/health has been negatively affected\/disrupted by my role as a caregiver is\u2026<\/label><ul id=\"wpforms-51-field_90\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_90_1\" name=\"wpforms[fields][90]\" value=\"Not at All\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_90_1\">Not at All<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_90_2\" name=\"wpforms[fields][90]\" value=\"Some\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_90_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_90_3\" name=\"wpforms[fields][90]\" value=\"Moderately\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_90_3\">Moderately<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_90_4\" name=\"wpforms[fields][90]\" value=\"Quite a Bit\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_90_4\">Quite a Bit<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_90_5\" name=\"wpforms[fields][90]\" value=\"Extremely\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_90_5\">Extremely<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_91-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_91\">My attention to and plan for the future of my financial\/employment condition\/health is...<\/label><ul id=\"wpforms-51-field_91\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_91_1\" name=\"wpforms[fields][91]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_91_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_91_2\" name=\"wpforms[fields][91]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_91_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_91_3\" name=\"wpforms[fields][91]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_91_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_91_4\" name=\"wpforms[fields][91]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_91_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_91_5\" name=\"wpforms[fields][91]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_91_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_92-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"92\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"5\" data-formid=\"51\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" style=\"display:none;\"><div id=\"wpforms-51-field_93-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"93\"><h3 id=\"wpforms-51-field_93\" name=\"wpforms[fields][93]\">Health of the Caregiving Landscape<\/h3><div class=\"wpforms-field-description\">This section of the assessment explores the health of your \u201cCaregiving Landscape.\u201d  The health of the care situation you are managing, including your recipient of care\u2019s health, their housing, and the collaboration of others--as it has a direct impact on your health. The below questions explore areas of that Landscape at a general level. <\/div><\/div><div id=\"wpforms-51-field_94-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"94\"><input type=\"hidden\" id=\"wpforms-51-field_94\" name=\"wpforms[fields][94]\" value=\".\"><\/div><div id=\"wpforms-51-field_95-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_95\">The physical health, including mobility, of my care recipient is....<\/label><ul id=\"wpforms-51-field_95\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_95_1\" name=\"wpforms[fields][95]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_95_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_95_2\" name=\"wpforms[fields][95]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_95_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_95_3\" name=\"wpforms[fields][95]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_95_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_95_4\" name=\"wpforms[fields][95]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_95_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_95_5\" name=\"wpforms[fields][95]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_95_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_96-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_96\">The mental and emotional  health of my care recipient (including their cognitive\/thinking abilities) is....<\/label><ul id=\"wpforms-51-field_96\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_96_1\" name=\"wpforms[fields][96]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_96_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_96_2\" name=\"wpforms[fields][96]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_96_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_96_3\" name=\"wpforms[fields][96]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_96_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_96_4\" name=\"wpforms[fields][96]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_96_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_96_5\" name=\"wpforms[fields][96]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_96_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_97-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_97\">The health of my care recipient\u2019s relationships with their family and other social connections is\u2026.<\/label><ul id=\"wpforms-51-field_97\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_97_1\" name=\"wpforms[fields][97]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_97_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_97_2\" name=\"wpforms[fields][97]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_97_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_97_3\" name=\"wpforms[fields][97]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_97_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_97_4\" name=\"wpforms[fields][97]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_97_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_97_5\" name=\"wpforms[fields][97]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_97_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_98-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_98\">My care recipient\u2019s sense of identity and purpose is\u2026.<\/label><ul id=\"wpforms-51-field_98\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_98_1\" name=\"wpforms[fields][98]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_98_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_98_2\" name=\"wpforms[fields][98]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_98_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_98_3\" name=\"wpforms[fields][98]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_98_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_98_4\" name=\"wpforms[fields][98]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_98_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_98_5\" name=\"wpforms[fields][98]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_98_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_99-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_99\">The financial and legal health of my care recipient is....<\/label><ul id=\"wpforms-51-field_99\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_99_1\" name=\"wpforms[fields][99]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_99_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_99_2\" name=\"wpforms[fields][99]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_99_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_99_3\" name=\"wpforms[fields][99]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_99_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_99_4\" name=\"wpforms[fields][99]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_99_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_99_5\" name=\"wpforms[fields][99]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_99_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_100-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_100\">The condition of my care recipient\u2019s housing and transportation is\u2026.<\/label><ul id=\"wpforms-51-field_100\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_100_1\" name=\"wpforms[fields][100]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_100_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_100_2\" name=\"wpforms[fields][100]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_100_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_100_3\" name=\"wpforms[fields][100]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_100_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_100_4\" name=\"wpforms[fields][100]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_100_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_100_5\" name=\"wpforms[fields][100]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_100_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_101-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_101\">The availability, balance, and quality of my care recipient\u2019s external services and outside help is\u2026.<\/label><ul id=\"wpforms-51-field_101\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_101_1\" name=\"wpforms[fields][101]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_101_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_101_2\" name=\"wpforms[fields][101]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_101_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_101_3\" name=\"wpforms[fields][101]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_101_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_101_4\" name=\"wpforms[fields][101]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_101_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_101_5\" name=\"wpforms[fields][101]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_101_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_102-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_102\">The degree to which my care recipient\u2019s situation is planned, monitored, and coordinated is\u2026. <\/label><ul id=\"wpforms-51-field_102\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_102_1\" name=\"wpforms[fields][102]\" value=\"Terrible\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_102_1\">Terrible<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_102_2\" name=\"wpforms[fields][102]\" value=\"Poor\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_102_2\">Poor<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_102_3\" name=\"wpforms[fields][102]\" value=\"Fair\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_102_3\">Fair<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_102_4\" name=\"wpforms[fields][102]\" value=\"Good\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_102_4\">Good<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_102_5\" name=\"wpforms[fields][102]\" value=\"Excellent\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_102_5\">Excellent<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_103-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"103\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"6\" data-formid=\"51\" disabled>Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 last \" style=\"display:none;\"><div id=\"wpforms-51-field_104-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"104\"><h3 id=\"wpforms-51-field_104\" name=\"wpforms[fields][104]\">DEMOGRAPHICS<\/h3><div class=\"wpforms-field-description\">(Optional -- Please fill out all fields that you are comfortable sharing with us; we will use this information to guide course and service creation.)<\/div><\/div><div id=\"wpforms-51-field_123-container\" class=\"wpforms-field wpforms-field-hidden\" data-field-id=\"123\"><input type=\"hidden\" id=\"wpforms-51-field_123\" name=\"wpforms[fields][123]\" value=\".\"><\/div><div id=\"wpforms-51-field_105-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"105\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_105\">Name<\/label><input type=\"text\" id=\"wpforms-51-field_105\" class=\"wpforms-field-medium\" name=\"wpforms[fields][105]\" ><\/div><div id=\"wpforms-51-field_106-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"106\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_106\">Age<\/label><input type=\"text\" id=\"wpforms-51-field_106\" class=\"wpforms-field-medium\" name=\"wpforms[fields][106]\" ><\/div><div id=\"wpforms-51-field_108-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"108\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_108\">Gender<\/label><select id=\"wpforms-51-field_108\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][108]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Male<\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><option value=\"Non-Binary\" >Non-Binary<\/option><option value=\"Prefer not to say\" >Prefer not to say<\/option><\/select><\/div><div id=\"wpforms-51-field_109-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"109\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_109\">Address<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-51-field_109\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][109][address1]\" ><label for=\"wpforms-51-field_109\" class=\"wpforms-field-sublabel after \">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-51-field_109-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][109][address2]\" ><label for=\"wpforms-51-field_109-address2\" class=\"wpforms-field-sublabel after \">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-51-field_109-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][109][city]\" ><label for=\"wpforms-51-field_109-city\" class=\"wpforms-field-sublabel after \">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-51-field_109-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][109][state]\" ><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-51-field_109-state\" class=\"wpforms-field-sublabel after \">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-51-field_109-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"99999[-9999]\" data-inputmask-greedy=\"false\" data-rule-empty-blanks=\"1\" name=\"wpforms[fields][109][postal]\" ><label for=\"wpforms-51-field_109-postal\" class=\"wpforms-field-sublabel after \">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-51-field_110-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"110\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_110\">Level of Education<\/label><select id=\"wpforms-51-field_110\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][110]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>High School<\/option><option value=\"High School\" >High School<\/option><option value=\"Some College\" >Some College<\/option><option value=\"Associate&#039;s\" >Associate&#039;s<\/option><option value=\"Bachelor&#039;s\" >Bachelor&#039;s<\/option><option value=\"Master&#039;s\" >Master&#039;s<\/option><option value=\"PhD\" >PhD<\/option><\/select><\/div><div id=\"wpforms-51-field_111-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"111\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_111\">Employment:<\/label><ul id=\"wpforms-51-field_111\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_111_1\" name=\"wpforms[fields][111]\" value=\"Part-Time\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_111_1\">Part-Time<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_111_2\" name=\"wpforms[fields][111]\" value=\"Full-Time\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_111_2\">Full-Time<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_111_3\" name=\"wpforms[fields][111]\" value=\"Self-Employed\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_111_3\">Self-Employed<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_111_4\" name=\"wpforms[fields][111]\" value=\"No Work\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_111_4\">No Work<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_112-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"112\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_112\">Number of Children<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-51-field_112\" class=\"wpforms-field-small\" name=\"wpforms[fields][112]\" ><\/div><div id=\"wpforms-51-field_113-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"113\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_113\">Children&#039;s Ages, if applicable:<\/label><input type=\"text\" id=\"wpforms-51-field_113\" class=\"wpforms-field-medium\" name=\"wpforms[fields][113]\" ><\/div><div id=\"wpforms-51-field_114-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"114\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_114\">Do children live with you? <\/label><ul id=\"wpforms-51-field_114\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_114_1\" name=\"wpforms[fields][114]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_114_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_114_2\" name=\"wpforms[fields][114]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_114_2\">No<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_114_3\" name=\"wpforms[fields][114]\" value=\"N\/A\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_114_3\">N\/A<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_115-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"115\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_115\">Recipient of Care Gender:<\/label><select id=\"wpforms-51-field_115\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"\" name=\"wpforms[fields][115]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Male<\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><option value=\"Prefer not to say\" >Prefer not to say<\/option><\/select><\/div><div id=\"wpforms-51-field_116-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"116\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_116\">Recipient of Care Age:<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-51-field_116\" class=\"wpforms-field-small\" name=\"wpforms[fields][116]\" ><\/div><div id=\"wpforms-51-field_117-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-modern\" data-field-id=\"117\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_117\">Recipient of Care Relationship -- The recipient of care is my: <\/label><select id=\"wpforms-51-field_117\" class=\"wpforms-field-medium choicesjs-select\" data-size-class=\"wpforms-field-row wpforms-field-medium\" data-search-enabled=\"1\" name=\"wpforms[fields][117]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Mother<\/option><option value=\"Mother\" >Mother<\/option><option value=\"Father\" >Father<\/option><option value=\"Grandmother\" >Grandmother<\/option><option value=\"Grandfather\" >Grandfather<\/option><option value=\"Spouse\/Significant Other\" >Spouse\/Significant Other<\/option><option value=\"Brother\" >Brother<\/option><option value=\"Sister\" >Sister<\/option><option value=\"Aunt\" >Aunt<\/option><option value=\"Uncle\" >Uncle<\/option><option value=\"Son\" >Son<\/option><option value=\"Daughter\" >Daughter<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-51-field_118-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"118\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_118\">Do you live with the recipient of care?<\/label><ul id=\"wpforms-51-field_118\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_118_1\" name=\"wpforms[fields][118]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_118_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_118_2\" name=\"wpforms[fields][118]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_118_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_120-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"120\"><label class=\"wpforms-field-label\" for=\"wpforms-51-field_120\">If yes:<\/label><ul id=\"wpforms-51-field_120\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_120_1\" name=\"wpforms[fields][120]\" value=\"Your Home\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_120_1\">Your Home<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-51-field_120_2\" name=\"wpforms[fields][120]\" value=\"Other\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-51-field_120_2\">Other<\/label><\/li><\/ul><\/div><div id=\"wpforms-51-field_121-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"121\"><label class=\"wpforms-field-label wpforms-label-hide\" for=\"wpforms-51-field_121\">Other Location<\/label><input type=\"text\" id=\"wpforms-51-field_121\" class=\"wpforms-field-large\" name=\"wpforms[fields][121]\" placeholder=\"Other location description\" ><\/div><div id=\"wpforms-51-field_14-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"14\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"51\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"1\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-51\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Processing...\" data-submit-text=\"Next\">Next<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/communityforcaregivers.com\/checkup\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"\"><\/div><\/form><\/div>  <!-- .wpforms-container -->\n<p>&nbsp;<\/p>\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>&nbsp; &nbsp;<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-27","page","type-page","status-publish","hentry","post"],"_links":{"self":[{"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/pages\/27","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/comments?post=27"}],"version-history":[{"count":13,"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/pages\/27\/revisions"}],"predecessor-version":[{"id":152,"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/pages\/27\/revisions\/152"}],"wp:attachment":[{"href":"https:\/\/communityforcaregivers.com\/checkup\/wp-json\/wp\/v2\/media?parent=27"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}