Caregiver self-assessment questionare

 

Caregiver self-assessmefit 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, turn the page to do a self-evaluation.

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

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

2.  Felt that I couldn't leave my relative alone............................□Yes  □No

3.  Had difficulty making decisions..................................□Yes  □No

4.  Felt completely overwhelmed......□Yes  □No

5.  Felt useful and needed...............□Yes  □No

6.  Felt lonely.................................□Yes  □No

7.  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.  Been edgy or irritable.................□Yes  □No

10.  Had sleep disturbed because of caring for my relative...........□Yes  □No

11.  Had a crying spell(s)................□Yes  □No

12.  Felt strained between work and family responsibilities………

13. Had back pain.........................□Yes □No

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

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

16.  Found my relative's living situation to be inconvenient or a barrier to care..,......□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.

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. _____

 

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;

•   If your score on question 18 is 6 or higher

 

Next steps

•   Consider seeing a doctor for a check-up for yourself

•   Consider having some relief from caregiving (Discuss with the doctor or a social worker the resources available in your community.)

•   Consider joining a support group

 

Valuable resources for caregivers

 

Eldercare Locator (a national directory of community services)

(800)677 1116

www.eldercare.gov

 

Family Caregiver Alliance

(415) 434-3388

www. caregiver.org

 

Medicare Hotline

(800) 633-4227

www. medicare.gov

 

National Alliance for Caregiving

(301) 718-8444

www. caregiving. org

 

National Family Caregivers Association

(800) 896-3650

www. nfcacares.org

 

National Information Center for Children

Youth with Disabilities

(800) 695-0285

www. nichcy.org