CAREGIVER ASSESSMENT
This form is intended to be filled out by a caregiver
1. How many dependent people do you care for on a regular basis?
a) Dependent adults (include care receiver)
b) Dependent children (under age 18)
2. The following are some thoughts and feelings that people sometimes experience when they assist their care receiver. As the following statements are read indicate the extent to which you agree or disagree with each statement.
| Strongly Disagree | Disagree | Disagree a Little | Agree a Little | Agree | Strongly Agree | |
|---|---|---|---|---|---|---|
a) The things I am responsible for do not fit very well with what I want to do. |
1
|
2
|
3
|
4
|
5
|
6
|
b) I am not sure that I can accept any more responsibility than I have right now. |
1
|
2
|
3
|
4
|
5
|
6
|
c) I am not always able to be the person I want to be when I am with my spouse/partner/parent. |
1
|
2
|
3
|
4
|
5
|
6
|
d) It is difficult for me to accept all the responsibility for my spouse/partner/parent. |
1
|
2
|
3
|
4
|
5
|
6
|
e) I am having trouble accepting the way I relate to my spouse/partner/parent. |
1
|
2
|
3
|
4
|
5
|
6
|
f) It is difficult for me to accept any more responsibility that I now have to assume. |
1
|
2
|
3
|
4
|
5
|
6
|
a) The things I am responsible for do not fit very well with what I want to do.
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
1
2
3
4
5
6
b) I am not sure that I can accept any more responsibility than I have right now.
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
1
2
3
4
5
6
c) I am not always able to be the person I want to be when I am with my spouse/partner/parent.
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
1
2
3
4
5
6
d) It is difficult for me to accept all the responsibility for my spouse/partner/parent.
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
1
2
3
4
5
6
e) I am having trouble accepting the way I relate to my spouse/partner/parent.
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
1
2
3
4
5
6
f) It is difficult for me to accept any more responsibility that I now have to assume.
Strongly Disagree
Disagree
Disagree a Little
Agree a Little
Agree
Strongly Agree
1
2
3
4
5
6
3. Given your relative's (care receiver) CURRENT CONDITION, would you consider placing him/her in a different type of care setting, such as a nursing home or another care facility for long-term placement?
Definitely not
Probably not
Probably would
Definitely would
Does not apply - relative is in a care facility
4. As a result of assisting your family member, have the following aspects of your life changed? Have your caregiving responsibilities......
| Not at all | A little | Moderately | A lot | A great deal | |
|---|---|---|---|---|---|
a) caused conflicts with your relative? |
1
|
2
|
3
|
4
|
5
|
b) decreased time you have to yourself? |
1
|
2
|
3
|
4
|
5
|
c) created a feeling of hopelessness? |
1
|
2
|
3
|
4
|
5
|
d) given your life more meaning? |
1
|
2
|
3
|
4
|
5
|
e) increased the number of unreasonable requests made by your relative? |
1
|
2
|
3
|
4
|
5
|
f) kept you from recreational activities? |
1
|
2
|
3
|
4
|
5
|
g) made you nervous? |
1
|
2
|
3
|
4
|
5
|
h) made you more satisfied with your relationship? |
1
|
2
|
3
|
4
|
5
|
a) caused conflicts with your relative?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
b) decreased time you have to yourself?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
c) created a feeling of hopelessness?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
d) given your life more meaning?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
e) increased the number of unreasonable requests made by your relative?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
f) kept you from recreational activities?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
g) made you nervous?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
h) made you more satisfied with your relationship?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
5. Have your caregiving responsibilities....
| Not at all | A little | Moderately | A lot | A great deal | |
|---|---|---|---|---|---|
a) caused you to feel that your relative makes demands over and above what he/she needs? |
1
|
2
|
3
|
4
|
5
|
b) caused your social life to suffer? |
1
|
2
|
3
|
4
|
5
|
c) depressed you? |
1
|
2
|
3
|
4
|
5
|
d) given you a sense of fulfillment? |
1
|
2
|
3
|
4
|
5
|
e) made you feel you were being taken advantage of by your relative? |
1
|
2
|
3
|
4
|
5
|
f) changed your routine? |
1
|
2
|
3
|
4
|
5
|
g) made you anxious? |
1
|
2
|
3
|
4
|
5
|
h) left you feeling good? |
1
|
2
|
3
|
4
|
5
|
a) caused you to feel that your relative makes demands over and above what he/she needs?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
b) caused your social life to suffer?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
c) depressed you?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
d) given you a sense of fulfillment?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
e) made you feel you were being taken advantage of by your relative?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
f) changed your routine?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
g) made you anxious?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
h) left you feeling good?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
6. Have your caregiving responsibilities.....
| Not at all | A little | Moderately | A lot | A great deal | |
|---|---|---|---|---|---|
a) increased attempts by your relative to manipulate you? |
1
|
2
|
3
|
4
|
5
|
b) given you little time for friends and relatives? |
1
|
2
|
3
|
4
|
5
|
c) caused you to worry? |
1
|
2
|
3
|
4
|
5
|
d) made you enjoy being with your relative more? |
1
|
2
|
3
|
4
|
5
|
e) left you with almost no time to relax? |
1
|
2
|
3
|
4
|
5
|
f) made you cherish your time with your relative? |
1
|
2
|
3
|
4
|
5
|
a) increased attempts by your relative to manipulate you?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
b) given you little time for friends and relatives?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
c) caused you to worry?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
d) made you enjoy being with your relative more?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
e) left you with almost no time to relax?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
f) made you cherish your time with your relative?
Not at all
A little
Moderately
A lot
A great deal
1
2
3
4
5
7. Now I am going to read you a list of statements about the way that you have felt in the past week. For each statement that I read tell me - how often you have felt this way in the past week.
| Rarely or none of the time (less than 1 day) | Some or a little of the time (1-2 days) | Occasionally or a moderate amount of time (3-4 days) | All of the time (5-7 days) | |
|---|---|---|---|---|
a) I was bothered by things that usually don't bother me. |
1
|
2
|
3
|
4
|
b) I had trouble keeping my mind on what I was doing. |
1
|
2
|
3
|
4
|
c) I felt depressed. |
1
|
2
|
3
|
4
|
d) I felt that everything I did was an effort. |
1
|
2
|
3
|
4
|
e) I felt hopeful about the future. |
1
|
2
|
3
|
4
|
f) I felt fearful. |
1
|
2
|
3
|
4
|
g) My sleep was restless. |
1
|
2
|
3
|
4
|
h) I was happy. |
1
|
2
|
3
|
4
|
i) I felt lonely. |
1
|
2
|
3
|
4
|
j) I could not "get going". |
1
|
2
|
3
|
4
|
a) I was bothered by things that usually don't bother me.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
b) I had trouble keeping my mind on what I was doing.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
c) I felt depressed.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
d) I felt that everything I did was an effort.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
e) I felt hopeful about the future.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
f) I felt fearful.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
g) My sleep was restless.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
h) I was happy.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
i) I felt lonely.
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
j) I could not "get going".
Rarely or none of the time (less than 1 day)
Some or a little of the time (1-2 days)
Occasionally or a moderate amount of time (3-4 days)
All of the time (5-7 days)
1
2
3
4
8. Which of the following best describes your care receiver?
No memory problem
Memory or cognitive problems suspected
Probable Alzheimer's disease or other dementia is suspected, but is not medically diagnosed
Yes, Alzheimers disease or other dementia has been medically diagnosed
Care Receiver First Name
Care Receiver Last Name
Relationship
Wife
Husband
Domestic partner
Mother
Father
Mother-in-law
Father-in-law
Grandmother
Grandfather
Brother
Sister
Son
Daughter
Others
Thanks for being a caregiver...
A family caregiver specialist from Metropolitan Family Services DuPage will be reaching out to you regarding next steps in getting you the tailored resources you need.
LEARN ABOUT TCARE