Caregiver self-assessment questionnaire
HOW ARE YOU?
Caregivers are often so concerned with caring for their relative’s needs that they lose sight of their own well-being. Please take just a moment to answer the following questions. Once you have answered the questions, turn the page to do a self-evaluation.
Answer the following questions with Y or N (yes or no) and keep track of your answers. There are only 16 question
(The questionnaire was borrowed from the AMA website, but is also used on the Alzheimer’s Association)
During the past week or so, I have …
1. Had trouble keeping my mind on what I was doing
2. Felt that I couldn’t leave my relative alone
3. Had difficulty making decisions
4. Felt completely overwhelmed
5. Felt useful and needed
6. Felt lonely
7. Been upset that my relative has changed so much from his/her former self
8. Felt a loss of privacy and/or personal time
9. Been edgy or irritable
10. Had sleep disturbed because of caring for my relative
11. Had a crying spell(s)
12. Felt strained between work and family responsibilities
13. Had back pain
14. Felt ill (headaches, stomach problems or common cold)
15. Been satisfied with the support my family has given me
16. Found my relatives living situation to be inconvenient or a barrier to care
On a scale of 1 to 10, with 1 being “not stressful” to 10 being “extremely stressful,” please rate your current level of stress ________ .
On a scale of 1 to 10, with 1 being “very healthy” to 10 being “very ill,” please rate your current health compared to what it was this time last year _________ .
To determine the score:
1. Reverse score questions 5 and 15.
(For example, a “No” response should be counted as “Yes” and a “Yes” response should be counted as “No.”)
2. Total the number of “yes” responses _______ .
To interpret the score
Chances are that you are experiencing a high degree of distress:
• If you answered “Yes” to either or both questions 4 and 11; or
• If your total “Yes” score = 10 or more; or
• If your score on question 17 is 6 or higher; or
• If your score on question 18 is 6 or higher
Consider seeing a doctor for a check-up for yourself
Consider having some relief from caregiving. For ideas that are “real” take a look at www.StopStressCold.com
(Discuss with the doctor or a social worker the resources available in your community.)
Better Still Go To www.easycaregiving.com Sign up for the mailing list and you will immediately get a FREE guided imagery recording. Full Length this recording is designed and written specifically for caregivers. You will be also get a couple of e-books about wandering and difficulty with bathing.