Caregiver Assessment - Taking care of you, the Caregiver.

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First, go through the following questions by yourself, or better yet, with an accountability partner or group. Think about what applies to your situation. Your answers are not connected to your e-mail or name, the data is collected in bulk.

Email *

What is your caregiving situation?

I live with my loved one

I live within driving distance of the person I care for

I am a long-distance caregiver

I am a paid caregiver for an unrelated person

Other:

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Are there other caregivers sharing the role with you? (Unpaid caregivers, not people in medical or other paid roles.)

No one, I am a sole caregiver

I have others that support the person needing care

There are other family members, but they help little or none

Other:

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How do you express the need for self-care with the person you take care of?

I know my limits and share them with my loved one

I don't bother to explain because they will not understand

I express my limits, but then go ahead and ignore them

I don’t think about my limitations, I just keep going

Other:

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Have you experienced any of the following symptoms of stress while being a caregiver – even one time? (Check as many as apply.)

Emotional stress – crying, outbursts, etc.

Physical symptoms

Mental confusion, fog

Forgetting your own or family appointments

Neglecting your own needs (for example not scheduling dental appointments)

Unable to fulfill family responsibilities

Missed work

Lack of sleep

Not exercising

Unhealthy eating

Other:

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