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.

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

Self-Evaluation to determine your score!

Reverse score questions 5 and 15. (for example: a “No” response should be counted as “Yes” and a “Yes” should be counted as “No.”)

Interpretation of your score.

Chances are 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;
  • If your score on questions 17 and 18 – is 6 or higher.

Your stress level is in the moderate category:

  • If you answered “Yes to either question 4 or 11; or
  • If your total “Yes” score is between 5 and 10;
  • If you answered “Yes” to either questions 17 or 18.

Next Steps:

Ø Consider a medical checkup.

Ø Seek respite care from community resources.

Ø Ask a family member to give you a break.

Ø Call your local faith community for possible assistance.

Ø Contact Butler Counseling & Consulting and The Guardians Gift for help to reduce your stress level.  You don’t have to do this alone.