Questionnaire: Family Caregiving and Elder Care Expenditures
问卷调查：家庭照顾和老年人护理支出

Section 1: Demographic Information
第 1 部分：人口统计信息

1.Age Group:
1.年龄组：

45–50

51–60

61–70

Over 70
70 岁以上

2.Education Level:
2.教育程度：

No schooling
没有学校教育

Primary school
小学

Junior high school
初中

Senior high school
高中

Junior college or higher
大专以上

3.Occupation:
3.职业：

Government employee
政府雇员

Enterprise worker
企业工作线程

Farmer
农民

Small private business owner
小型私营企业主

Retired
退休

Unemployed
失业的

Other (please specify): __________
其他（请注明）：__________

4.Area of Residence:
4.居住面积：

Urban
都市的

Rural
农村

Marital status:
婚姻状况：

Single
单

Married
已婚

Divorced/Separated
离婚/分居

Widowed
寡

6.Monthly Per Capita Income (1,000 RMB):
6.月人均收入（1,000元）：

Less than 1,000 RMB
1000元以下

1,001–3,000 RMB
1,001 – 3,000 元

3,001–5,000 RMB
3,001 – 5,000 元

5,001–10,000 RMB
5,001 – 10,000 元

Over 10,000 RMB
10,000 元以上

Section 2: Healthcare and Accessibility
第 2 部分：医疗保健和可及性

1..Is the Nearest Hospital Easily Accessible to You?
1..您容易到达最近的医院吗？

Yes
是的

No
不

2.Type of Nearest Hospital:
2.最近的医院类型：

Public hospital (Grade I, II, or III)
公立医院（I、II 或 III 级）

Private hospital
私立医院

Community healthcare center
社区保健中心

Traditional Chinese medicine clinic
中医诊所

Other (please specify): __________
其他（请注明）：__________

3.Distance to the Nearest Healthcare Facility (in meters)
3.到最近的医疗机构的距离（以米为单位）

Less than or equal to 500 meters
小于或等于 500 米

501–1,000 meters
501–1000 米

More than 1,000 meters
超过 1,000 米

4. Perceived Healthcare Quality:
4. 感知的医疗保健质量：

Strongly agree
非常同意

Agree
同意

Neutral
中性

Disagree
反对

Strongly disagree
非常不同意

5.Do You Find Healthcare Services Near You Affordable?
5.您觉得您附近的医疗保健服务负担得起吗？

1. Yes
1. 是的

2.No

Section 3: Caregiving Responsibilities
第 3 部分：照护责任

1.Who Do You Primarily Care For?
1.您主要照顾谁？

Parent
父母

Spouse
配偶

Other relative
其他亲属

Non-relative
非相对

2.How Many Hours Per Week Do You Spend Caregiving?
2.您每周花多少小时照顾孩子？

Less than 10 hours
少于 10 小时

10–20 hours
10 - 20 小时

21–40 hours
21–40 小时

Over 40 hours
超过 40 小时

3.What Type of Care Do You Provide? (Check all that apply)
3.你们提供什么类型的护理？（勾选所有适用项）

Assistance with daily activities (e.g., bathing, dressing, eating)
协助日常活动（例如，洗澡、穿衣、吃饭）

Medical care (e.g., administering medication, therapy)
医疗护理（例如，给药、治疗）

Financial support
财务支持

Emotional support
情感支持

Other (please specify): ___________
其他（请注明）：___________

4.What Is the Current Condition of the Person You Are Caring For?
4.您照顾的人目前的状况如何？

Healthy
健康

Requires occasional assistance
需要偶尔的帮助

Requires frequent assistance
需要频繁的帮助

Dependent on full-time care
依赖全职护理

Section 4: Financial and Social Support
第 4 部分 财政和社会支持

1.What Percentage of Your Household Income Is Spent on Caregiving-Related Expenses?
1.您的家庭收入中有多少百分比用于护理相关费用？

Less than 10%
小于 10%

11–20%

21–30%

Over 30%
超过 30%

2.Do You Receive Financial Assistance for Caregiving?
2.您是否获得护理经济援助？

Yes
是的

No
不

I’m not aware of any available subsidies
我不知道有任何可用的补贴

3.Do You Have a Support Network for Caregiving?
3.有护理支援网络吗？

Yes, always
是的，总是

Sometimes
有时

Rarely
很少

Never
从不

4.If Yes, Where Does Your Support Come From? (Check all that apply)
4.如果有，您的支持从何而来？（勾选所有适用项）

Family members
家人

Friends
朋友

Community or local organizations
社区或当地组织

Government programs
政府项目

Other (please specify): __________
其他（请注明）：__________

Section 5: Chronic Disease and Healthcare Usage
第 5 部分：慢性病和医疗保健使用

1.Do You or the Person You Are Caring For Have Any Chronic Diseases?
1.您或您照顾的人患有任何慢性疾病吗？

No chronic diseases
无慢性疾病

One or more chronic diseases (please specify): __________
一种或多种慢性疾病（请注明）：__________

2.Number of Visits to the Hospital in the Past Year:
2.近一年就诊次数：

None
没有

1–5 visits
1-5 次访问

6–10 visits
6-10 次访问

More than 10 visits
超过 10 次访问

3.Do You Feel You Have Enough Information About Caregiving Resources (e.g., financial subsidies, healthcare services, support networks)?
您 3.Do 觉得自己有足够的关于护理资源（例如，财政补贴、医疗保健服务、支持网络）的信息？

Yes
是的

No
不

4.How Would You Describe Your Physical and Mental Health as a Caregiver?
4.您如何描述自己作为护理人员的身心健康状况？

Excellent
非常好

Good
好

Fair
公平

Poor
穷

Section 6: Additional Comments (Optional)
第 6 部分：其他注释（可选）

If you have any additional information or clarifications regarding your responses, please provide them here:
如果您对您的回答有任何其他信息或说明，请在此处提供：