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Name: To Lauren | Date: Apr 18th, 2006 9:04 PM |
1-yes 2-1 3-3 months 4-payroll 5-FT & Night shift at home 6-40 7-yes (40) 8-chores (sometimes)Bills(always)Grocery(always) 9-Homework(N/A)Drive(always)Appointment s(always) 10-none 11-day(none)Week(1/2 day) 12-laundry, vacuum 13-yes 14-yes 15-me 16-2-3 17-yes (all) 18-me 19-husband 20- 1998 mercury mystique, 2001 pontiac grand am gt ↑ |
Name: WM in NC | Date: May 11th, 2006 4:05 PM |
Questionnaire 1. Are you married? Yes 2. How many kids do you have? 2 3. How old are your children? 3 and 6 4. What type of profession do you work in? Finance 5. Please indicate any of the following that apply: ❏ Works part-time (less than 40 hrs a week) ❏ Works full-time (more than 40 hrs a week) ❏ Works part-time and the night shift at home ❏ Works full-time and the night shift at home - yes 6. How many hours in total do you work a week? For the paying job - about 45 7. Does your husband work? If so please indicate the number of hours per week ❏ Yes ❏ No - No Number of hours 8. Please indicate the following household tasks that you are responsible for: Household chores: Always Sometimes Rarely - Sometimes Paying Bills: Always Sometimes Rarely - Rarely Cooking & Preparing Meals: Always Sometimes Rarely - Always Grocery Shopping: Always Sometimes Rarely - Always 9. Please indicate the following child care responsibilities that you are responsible for: Homework Help: Always Sometimes Rarely - Always Put the kids to bed: Always Sometimes Rarely - Shared Drive kids to school & any activities: Always Sometimes Rarely - shared Take kids to any appointments (ie: docter, dentist) Always Sometimes Rarely - shared 10. What time and energy saver strategies do you use? Please indicate all that apply ❏ Eating Out/Take-out - sometimes ❏ Cleaning Lady ❏ Nanny/ Mother’s helper ❏ Other 11. How much leisure time do you have? In a day? 1 hour In a week? 5 hours 12. What do you do with your leisure time? Read the newspaper/magazines/books 13. Are you always on the go? Do you feel there is not enough time in a day to get everything done? ❏ Yes - Yes ❏ No - ❏ Sometimes 14. Do you ever feel guilty letting others help out? Yes - As a mother you want to be involved in everything your kids are doing. 15. Who gets sick more often, you or your husband? We rarely get sick - (knock on wood) 16. How would you rate your energy level on a regular day? 1 2 3 4 - 3 17. Do you ever experience any health issues? ❏ yes - back pain ❏ no If yes, please check all that apply ❏ headache - yes ❏ fatigue ❏ back aches/pains - yes ❏ common-cold ❏ high stress levels - yes ❏ feelings of anxiety and/or depression 18. When a child is sick, who stays home to take care of him/or her? Husband 19. Who makes the higher income? I do 20. What kind of cars do each of you drive? 2003 Toyota minivan, 1999 Chevy Truck ↑ |
Name: Andrea | Date: Jun 6th, 2006 4:49 PM |
1. Are you married? Yes 2. How many kids do you have? 1 3. How old are your children? 2 years old 4. What type of profession do you work in? Transportation 5. Please indicate any of the following that apply: ❏ Works part-time (less than 40 hrs a week) X Works full-time (more than 40 hrs a week) ❏ Works part-time and the night shift at home ❏ Works full-time and the night shift at home 6. How many hours in total do you work a week? 45 7. Does your husband work? If so please indicate the number of hours per week X Yes ❏ No Number of hours 40-50 8. Please indicate the following household tasks that you are responsible for: Household chores: Sometimes Paying Bills: ALWAYS Cooking & Preparing Meals: Sometimes Grocery Shopping: Always 9. Please indicate the following child care responsibilities that you are responsible for: Homework Help: No homework yet Put the kids to bed: Sometimes Drive kids to school & any activities: Always Take kids to any appointments (ie: docter, dentist) Always 10. What time and energy saver strategies do you use? Please indicate all that apply X Eating Out/Take-out ❏ Cleaning Lady X Nanny/ Mother’s helper ❏ Other 11. How much leisure time do you have? In a day? 1 hour --maybe In a week? 4-5 hours 12. What do you do with your leisure time? Spend quality time with my husband 13. Are you always on the go? Do you feel there is not enough time in a day to get everything done? X Yes ❏ No ❏ Sometimes 14. Do you ever feel guilty letting others help out? Sometimes 15. Who gets sick more often, you or your husband? Me 16. How would you rate your energy level on a regular day? 3 17. Do you ever experience any health issues? yes If yes, please check all that apply X headache X fatigue X back aches/pains ❏ common-cold Xhigh stress levels X feelings of anxiety and/or depression 18. When a child is sick, who stays home to take care of him/or her? Me 19. Who makes the higher income? Me 20. What kind of cars do each of you drive? Honda ↑ |
Name: TAM | Date: Jun 7th, 2006 3:26 AM |
1. Are you married? YES 2. How many kids do you have? 4 3. How old are your children? 7 MTHS, 2, 10, 12 4. What type of profession do you work in? HEALTHCARE 5. Please indicate any of the following that apply: ❏ Works part-time (less than 40 hrs a week) ❏ Works full-time (more than 40 hrs a week) ❏ Works part-time and the night shift at home ❏ Works full-time and the night shift at homeYES 6. How many hours in total do you work a week? 40-42 7. Does your husband work? If so please indicate the number of hours per weekYES, 40-45 ❏ Yes ❏ No Number of hours 8. Please indicate the following household tasks that you are responsible for: Household chores: Always Sometimes Rarely- ALWAYS Paying Bills: Always Sometimes Rarely- ALWAYS Cooking & Preparing Meals: Always Sometimes Rarely- ALWAYS Grocery Shopping: Always Sometimes Rarely- ALWAYS 9. Please indicate the following child care responsibilities that you are responsible for: Homework Help: Always Sometimes Rarely ALWAYS Put the kids to bed: Always Sometimes RarelySOMETIMES Drive kids to school & any activities: Always Sometimes Rarely SOMETIMES Take kids to any appointments (ie: docter, dentist) Always Sometimes Rarely- ALWAYS 10. What time and energy saver strategies do you use? Please indicate all that apply ❏ Eating Out/Take-outSOMETIMES ❏ Cleaning Lady- R U KIDDING??? ❏ Nanny/ Mother’s helper I WISH ❏ Other 11. How much leisure time do you have? In a day? 30 MINUTES In a week?3-4 HRS 12. What do you do with your leisure time? PLAY BASKETBALL OR SLEEP 13. Are you always on the go? Do you feel there is not enough time in a day to get everything done?YES, YES ❏ Yes ❏ No ❏ Sometimes 14. Do you ever feel guilty letting others help out?ALWAYS 15. Who gets sick more often, you or your husband?ME- BUT NOT OFTEN- MAYBE 2X/YR 16. How would you rate your energy level on a regular day? 1 2 3 4- 3 17. Do you ever experience any health issues? ANXIETY- CONTINUE TO BE TREATED FOR PPD ❏ yes ❏ no If yes, please check all that apply ❏ headache ❏ fatigue ❏ back aches/pains ❏ common-cold ❏ high stress levels ❏ feelings of anxiety and/or depression 18. When a child is sick, who stays home to take care of him/or her?ME 19. Who makes the higher income? HUSBAND IS SL HIGHER 20. What kind of cars do each of you drive? 2004 MINIVAN, 2003 TRAILBLAZER ↑ |