Caregiver Self-Assessment Questionnaire

Courtesy of the American Medical Association

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 just a moment to answer the following questionnaire. Once you have answered the questions, you can do a self-evaluation.

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

Yes No Had trouble keeping my mind on what I was doing.
Yes No Felt that I couldn't leave my relative alone.
Yes No Had difficulty making decisions.
Yes No Felt completely overwhelmed.
Yes No Felt useful and needed.
Yes No Felt lonely.
Yes No Been upset that my relative has changed so much from his/her former self.
Yes No Felt a loss of privacy and/or personal time.
Yes No Been edgy or irritable.
Yes No Had sleep disturbed because of caring for my relative.
Yes No Had a crying spell(s).
Yes No Felt strained between work and family responsibilities.
Yes No Had back pain.
Yes No Felt ill (headaches, stomach problems or common cold).
Yes No Been satisfied with the support my family has given me.
Yes No Found my relative's living situation to be inconvenient or a barrier to care.
On a scale of 1-10,with 1 being "not stressful" to 10 being "extremely stressful," please rate your current level of stress.
On a scale of 1-10, with 1 being "very healthy" to 10 being "very ill," please rate your current health compared to what it was this time last year.