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, follow the self-evaluation instructions.

During the past week or so, 1...


1. Had trouble keeping my mind on what I was doing ................. Yes     No 16. Found my relative's living situation to be inconvenient or a barrier to care................... Yes     No
       
2. Felt that I couldn't leave my relative alone Yes     No 17. On a scale of 1 to 10, with 1 being "not stressful" to 10 being "extremely stressful," please rate your current level of stress.
       
3. Had difficulty making decisions ............ Yes     No 18. 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.
       
4. Felt completely overwhelmed ................ Yes     No

Self- Evaluation


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.
Next Steps:
  • Consider seeing a doctor for a check­up for yourself.
  • Consider joining a support group.
  • Consider having some assistance or relief from caregiving. (Discuss with a social worker or an PHCSI Information & Assistance specialist the resources available in your community.)
       
5. Felt useful and needed ........................ Yes     No
       
6. Felt lonely ....................................... Yes     No
       
7. Have been upset that my relative has changed so much from his/her former self.................... Yes     No
       
8. Felt a loss of privacy and/or personal time........................... Yes     No
       
9. Have been edgy or irritable...... Yes     No
       
10. Had sleep disturbed because of caring for my relative ............... Yes     No
       
11. Had a crying speU(s)................ Yes     No
       
12. Felt strained between work & family responsibilities............... Yes     No
       
13. Had back pain.......................... Yes     No
       
14. Felt iU (headaches, stomach problems or common cold) ...... Yes     No
       
15. Have been satisfied with the support that my family has given me ..... Yes     No
       

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