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Caregiver Assessment Form

Caregivers are often so concerned with caring for the relative’s needs that they lose sight of their own well-being. Please take just a moment to do a self evaluation by answering the following questions.

Had trouble keeping my mind on what I was doing
Had difficulty making decisions
Felt useful and needed
Felt a loss of privacy and/or personal time
Been upset that my relative has changed so much from his/her former self
Had a crying spell(s)
Had back pain
Been satisfied with the support my family has given me
Felt that I couldn't leave my relative alone
Felt completely overwhelmed
Felt lonely
Been edgy or irritable
Had sleep disturbed because of caring for my relative
Felt strained between work and family responsibilities
Felt ill (headaches, stomach problems or common cold)
Found my relative's living situation to be inconvenient or a barrier to care
On a scale of 1 to 5, with 1 being "not stressful" to 5 being "extremely stressful", please rate your current level of stress
On a scale of 1 to 5, with 1 being "very healthy" to 5 being "very ill", please rate your current health compared to what it was last year

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