Caregiver Self Assessment

Caregiver self-assessment questionnaire

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, see below to determine what you may consider next. If you would like a complimentary assessment of your loved one’s situation and assistance in developing a plan of care, call At Home Healthcare at 877-MY-NURSE or email info@athomehealth.org.

During the past week or so, I have … (answer ‘yes’ or ‘no’ to each question)

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 lonely.

6. Been upset that my relative has changed so much from his/her former self.

7. Felt a loss of privacy and/or personal time.

8. Been edgy or irritable.

9. Had sleep disturbed because of caring for my relative.

10. Had a crying spell(s).

11. Felt strained between work and family responsibilities.

12. Had back pain.

13. Felt ill (headaches, stomach problems or common cold).

14. Been unsatisfied with the support my family has given me.

15. Found my relative’s living situation to be inconvenient or a barrier to care.

16. On a scale of 1 to 10, with 1 being “not stressful” to 10 being “extremely stressful,” please rate your current level of stress.

17. 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.