Council on Aging Senior Guide 2012 - 94

COUNCIL ON AGING ORANGE COUNTY

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 well-being. Please take just a moment to answer the following questions. Once you have answered the questions, follow the self-evaluation instructions.

During the past week or so, I…
1. 2. 3. 4. 5. 6. 7. Had trouble keeping my mind on what I was doing .................. Felt that I couldn’t leave my relative alone............................. Had difficulty making decisions ................................... Felt completely overwhelmed............................. Felt useful and needed ............. Felt lonely.................................. Yes Yes Yes Yes Yes Yes No No No No No No 16. Found my relative’s living situation to be inconvenient or a barrier to care ....................

Yes

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. __________

Self – Evaluation
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.

Have been upset that my relative has changed so much from his/her former self..................... Yes Felt a loss of privacy and/or personal time ............................ Have been edgy or irritable ...... Yes Yes Yes Yes Yes Yes Yes

No No No No No No No No No

8. 9.

To Interpret the Score:

10. Had sleep disturbed because of caring for my relative ................ 11. Had a crying spell(s)................. 12. Felt strained between work & family responsibilities ................ 13. Had back pain ........................... 14. Felt ill (headaches, stomach problems or common cold).......

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.

15. Have been satisfied with the support that my family has given me...... Yes

Next Steps: • Consider seeing a doctor for a checkup for yourself. • Consider joining a support group. • Consider having some assistance or relief from caregivi ng. (Discuss with a social worker or an Office on Aging Information & Assistance specialist the resources available in your community.)

Information & Assistance - (800) 510-2020
For Older Adults, Families & Caregivers
94
Senior Guide OC 2012 Aging and Disability Resource Connection | 800-510-2020 | www.adrcoc.org

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Council on Aging Senior Guide 2012

Table of Contents for the Digital Edition of Council on Aging Senior Guide 2012