Caregiver Survey

Being a caregiver for a loved one can be a very rewarding It can also be very exhausting and stressful The survey below is designed to help identify how stressful your current situation is and provides information on whom to contact for help in alleviating the stress Loving and taking care of oneself is the first step to providing loving care to another

For each of the following questions, choose the answer that most closely matches your situation.
Question Answer
1. I have been so involved with providing care that I have not taken time off from that responsibility for several months. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
2. There is no one else who can provide care in my place. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
3. The person for whom I provide care requires assistance with two or more of the following activities: bathing, dressing, eating, toileting, or moving around. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
4. I cannot seem to get enough rest. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
5. I am afraid that if I leave the person for whom I provide care for more than a couple of hours, something bad might happen to him or her. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
6. My needs are not important in comparison to the needs of the person for whom I provide care. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
7. I frequently feel as though I am not doing enough to provide care. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
8. I do not seem to have enough time to take care of my own health. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
9. My own health problems make it difficult for me to provide care. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
10. I cannot seem to find enough time to take care of errands. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
11. I do not know whom I would call if I could not provide the care to my loved one myself. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
12. I do not feel like I can share my difficulties in providing care with anyone else. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
13. It seems I feel lonely more often these days. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
14. If you are working full-time:  I have missed many days of work because of caregiving responsibilities. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
15. I work part-time rather than full-time solely because of my caregiving responsibilities. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
16. I rarely have the opportunity to sit down or take a break during the day. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
17. There are never enough hours in the day anymore. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
18. I am strongly committed to providing care. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
19. I feel badly if I get frustrated in providing care. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
20. I try to do the "right" thing in providing care no matter what the cost is to me personally. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
21. My life is not my own anymore. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
22. I give myself credit for my willingness to persevere as a caregiver. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
23. I sometimes resent it that my family and/or friends do not provide me with help in caregiving. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
24. If money were no object, I would hire someone to provide full-time care rather than provide the care myself. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
25. I have no one to provide care for me. Strongly Agree
Agree
Don't Know
Disagree
Strongly Disagree
                
Total:

If your total score equals:

100-125: You are probably experiencing significant stress as a caregiver. Consider contacting one of the area agencies or call the Senior Hotline to Help at (608) 266-9007 to identify services to assist you in relieving some of your stress.

75-99:  You are probably experiencing some stress as a caregiver. Consider contacting one of the area agencies or call the Senior Hotline to Help at (608) 266-9007 to identify services to assist you in relieving some of your stress.

50-74:  You are probably experiencing occasional stress as a caregiver. You may wish to contact one of the area agencies or call the Senior Hotline to Help at (608) 266-9007 to identify services to assist you as a caregiver which might help you now or at some point in the future.

30-49: You probably have some current support from family, friends or other sources within the community to assist you in your caregiving. You may still be interested in contacting one of the area agencies to see about the availability of services to support you in caregiving, or to lend your experiences to other caregivers who are experiencing greater stress.

25-29:   You probably have a strong support system to assist you in caregiving. Nevertheless, feel free to contact one of the area agencies to see about the availability of services to support you in caregiving, or to lend your experiences to other caregivers who are experiencing greater stress.

 

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