Caregiver Self-Assessment Questionnaire

HOW ARE YOU?

Tally the number of "yes" responses and the number of "no" responses for the following questions:

In your role as caregiver, have you ever...

 1.    had trouble keeping your mind on what you are doing?

 2.    felt comfortable leaving your relative alone?

 3.    had difficulty making decisions?

 4.    felt completely overwhelmed?

 5.    felt useful and needed?

 6.    felt lonely?

 7.    been upset that your relative has changed to 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 your 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 your family has given you?

16.  found your relative's living situation to be inconvenient or a barrier to care?