Assessment Form

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

1 Had trouble keeping my mind on what I was doing.
2 Felt that I couldn't leave my relative alone.
3 Had diffculty 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" to 10 being "very ill," please rate your current health compared to what it was this time last year.

Interpreting your score

  • Chances are that you are experiencing a high degree of distress if one or more of the following statements are true.
  • Your score in Part One is 10 or more.
  • Your current level of stress was 6 or higher.
  • Your decline in health was 6 or higher.
  • You felt completely overwhelmed.
  • You had a crying spell(s).

Next Steps

  • Consider seeing a doctor for a check-up for yourself.
  • Consider joining a support group.
  • Consider having some professional caregiver relief. Click here to complete an online service request or call our offices for more information.