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Assured Assisted Living (303) 814-2688

Caregiver Self-Assessment Questionaire

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 difficulty making decisions.
  4. Felt completely overwhelmed.
  5. Felt useless and uneeded.
  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 and irritable.
  10. Had sleep disturbed because of caring for relative.
  11. Had a crying spell or spells.
  12. Felt strained between work and family responsibilities.
  13. Had back pain.
  14. Felt ill (headaches, stomach problems or common cold).
  15. Been dissatisfied with the support my family has given me.
  16. Found that my relatives living situation to be inconvenient or a barrier to care.
  17. On a scale of 1 to 10, with 1 being "not stressed" to 10 being "extremely stressefull", please rate your current level of stress.
  18. On a scale of 1 to 10, with 1 being "very healthy" to 10 being "extremely ill" please rate your current health compared to what it was this time last year.
To determine the score total the number of "yes" responses. Chances are you are experiencing a high degree of distress if your total score is 10 or more; you answered "yes" to questions 4 and 11 or your score on either question 17 or 18 was 6 or higher.
 
Next Steps:
  • Consider seeing a doctor for a check-up for yourself.
  • Consider having some relief from caregiving. Contact Assured Assisted Living. Short respite and daycare is also available.
  • Consider joining a support group.

Assured Assisted Living, LLC
4833 S. Front St., Unit B-123
Castle Rock, CO 80104 
(303) 814-2688
(303) 814-2689 Fax