Caregiving: caregiver self-assessment questionnaire

American Medical Association

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 wellbeing. Please take just a moment to answer the following questions. Once you have answered the questions, 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.

     .........❑Yes ❑No

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.

     _______

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; or

• If your score on Question 18 is 6 or higher.

 

Caregivingly Yours, Patrick Leer

Tags: caregiving, Caregiver Self-Assessment Questionnaire