Caregiver Self-Assessment Questionnaire - National Caregivers ...

TIONCaregiver Self-AssessmentQuestionnaireHow are you?American Medical AssociationPhysicians dedicated to the health of America515 Distributed North State by: StreetERICAMANMEDICALAASSOCICaregivers are often so concerned with caring for their relative’s needs that they lose sightof their own wellbeing. Please take just a moment to answer the following questions. Once youhave answered the questions, turn the page to do a self-evaluation.During the past week or so, I have...1. Had trouble keeping my mindon what I was doing ...................❑Yes❑No15.Been satisfied with the supportmy family has given me ..............❑Yes❑No2. Felt that I couldn’t leave myrelative alone................................❑Yes3. Had difficulty makingdecisions .....................................❑Yes❑No❑No4. Felt completely overwhelmed.......❑Yes ❑No5. Felt useful and needed ...............❑Yes ❑No6. Felt lonely ...................................❑Yes ❑No7. Been upset that my relative haschanged so much from his/herformer self....................................❑Yes8. Felt a loss of privacy and/orpersonal time ..............................❑Yes❑No❑No9. Been edgy or irritable ..................❑Yes ❑No10.Had sleep disturbed becauseof caring for my relative ..............❑Yes11.Had a crying spell(s) ...................❑Yes12.Felt strained between workand family responsibilities............❑Yes13.Had back pain .............................❑Yes14.Felt ill (headaches, stomachproblems or common cold) .............❑Yes❑No❑No❑No❑No❑No16.Found my relative’s living situationto be inconvenient or a barrierto care ........................................❑Yes❑No17.On a scale of 1 to 10,with 1 being “not stressful” to 10 being“extremely stressful,” please rate your currentlevel of stress. _______18.On a scale of 1 to 10,with 1 being “very healthy” to 10 being “veryill,” please rate your current health compared towhat it was this time last year. _______Comments:(Please feel free to comment or provide feedback)________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________For additional tools for caregiving or aging, visit www.CaregiversLibrary.org

Self-evaluation:To Determine the Score:1.Reverse score questions5 and 15. (For example,a “No” response should becounted as “Yes” and a“Yes” response should becounted as “No”)2.Total the numberof “yes” responses.To Interpret the Score:Chances are that youare experiencing a highdegree of distress:• If you answered “Yes” toeither or both Questions4 and 11; or• If your total “Yes” score= 10 or more; or• If your score onQuestion 17 is 6 orhigher; or• If your score onQuestion 18 is 6 orhigher.Next steps:• Consider seeing adoctor for a check-upfor yourself.• Consider having somerelief from caregiving.(Discuss with thedoctor or a social workerthe resources available inyourcommunity.)• Consider joining asupport groupValuable Resourcesfor Caregivers:Eldercare Locator:(a national directory ofcommunity services)1-800- 677-1116www.aoa.gov/elderpage/locator.htmlFamily Caregiver Alliance1-415- 434-3388www.caregiver.orgMedicaid HotlineBaltimore, MD1-800-638-6833National Alliance forCaregiving1-301-718-8444www.caregiving.orgNational FamilyCaregivers Association1-800 896-3650www.nfcacares.orgNational InformationCenter for Children andYouth with Disabilities1-800-695-0285www.nichcy.orgLocal Resources and Contacts:For additional tools for caregiving or aging, visit www.CaregiversLibrary.org