About
this survey: Being a family caregiver has its ups and downs.
Use this survey to learn more about how you're doing. Sometimes you
are so focused on helping your loved one that you forget to
monitor
HOW ARE YOU DOING? This survey will help you learn more about your
stress and will provide some suggestions for services.
Instructions:
Answer Yes or No to the following questions by clicking the radio
button next to each statement. Click the Calculate Score button
when you finish and then read the survey key (located below this
survey) to determine your level of distress.
Yes
No
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/care recipient alone.
3.
Had difficulty making decisions.
4.
Felt completely overwhelmed.
5.
Felt useful and needed.
6.
Felt lonely.
7.
Been upset that my relative/care recipient has changed so
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 my relative/care
recipient.
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 my family has given me.
16.
Found my relative's/care recipient's living situation to be
inconvenient or a barrier to care.
17.
On a scale of 1 to 10, with 1 being "not stressful"
and 10 being "extremely stressful," please rate
your current level of stress.
18.
On a scale of 1 to 10, with 1 being "very healthy"
and 10 being "very ill," please rate your current
health compared to what it was this time last year.
Your Score
If
Your Score Is:
It
Means...
9
or less
Chances
are, you have a low degree
of distress.
10
or more
Chances
are, you have a high degree
of distress.
Note:
If you answered
"Yes" to either or both Questions 4 and 11, you have
a high degree of distress.
If your
score on Question 17 or 18 is 6 or higher, you have a high degree
of distress.
If
your score indicates a high degree of distress, we recommend that
you consider professional assistance. Click the link below for
more information:
