Caregiver Assessement Tool

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 a moment to answer the following questions. Once you have answered, turn the page to do a self-evaluation.

Yes No


[ ] [ ] 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 useful and needed.

[ ] [ ] 6. Felt lonely.

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

[ ] [ ] 8. Felt a loss of privacy and/or personal time.

[ ] [ ] 9. Been edgy or irritable.

[ ] [ ] 10. Had sleep disturbed because of caring for my relative.

[ ] [ ] 11. Had a crying spell(s).

[ ] [ ] 12. Felt strained between work and family responsibilities.

[ ] [ ] 13. Had back pain.

[ ] [ ] 14. Felt ill (headaches, stomach problems or common cold).

[ ] [ ] 15. Been satisfied with the support my family has given me.

[ ] [ ] 16. Found my relative’s living situation to be inconvenient or a
barrier to care.

_________ 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” and 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 you score on Question 17 is 6 or higher; or
• If your score on Question 18 is 6 or higher.


Our thanks for this Self Assessment to:
American Medical Association Physicians
Dedicated to the health of America
515 North State Street, Chicago, Illinois, 60610
and to Caregiver Coalition of San Diego
www.sandiego.networkorcare.org/aging
800-510-2020


This assessment form provided to you today, courtesy of:

Nancy Beland, Owner 760-522-6478
starfishresources@gmail.com
www.starfishresources.net