Caregiver's Self-Assessment List

 

During the past week or so, I have....

 1.  Had trouble keeping my mind on what I was doing.    Yes    No

 2.  Had difficulty making decisions.    Yes    No

 3.  Felt completely overwhelmed.    Yes    No

 4.  Felt useful and needed.    Yes    No

 5.  Felt lonely.    Yes    No

 6.  Been upset that my relative/friend has changed so much from his/her former self.    Yes    No

 7.  Felt a loss of privacy and/or personal time.    Yes    No

 8.  Been edgy or irritable.    Yes    No

 9.  Had sleep disturbed because of caring for my relative/friend.    Yes    No

10.  Had a crying spell(s).    Yes    No

11.  Felt strained between work and family responsibilities.    Yes    No

12.  Had back pain.    Yes    No

13.  Felt ill (headaches, stomach problems, or common cold)    Yes    No

14.  Been satisfied with the support my family has given me.    Yes    No

15.  Found my relative/friend's living situation to be inconvenient or a barrier to care.    Yes    No

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:   

 

Self Evaluation:

To Determine the Score:

1.  Reverse score questions 4 and 14 (For example a “No” response should be counted as “Yes” and a “Yes” 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:

Next steps:

 

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