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care receivers

VIEWS: 7 PAGES: 2

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									                                                                                          www.eldercarepartners.org
                                                                                                     651-234-2262




A Caregiver Self Assessment1
Please answer each item as honestly as possible by circling the number in that best fits your response. The “care
receiver” is the person to whom you have been providing care. Use the scoring guide on page two to help you
evaluate your personal score.


                                                   Nearly                                 Almost         Not
                                                             Frequently Sometimes
                                                   Always                                 Never       Applicable
      I feel closer to my care receiver than
1)                                                   3            2             1             0           N/A
      ever before.
      My faith has been a source of strength
2)    and comfort for me while caring for my         3            2             1             0           N/A
      care receiver.
      I feel that, because of the time I spend
3)    with my care receiver, I do not have           3            2             1             0           N/A
      enough time for myself.
      I feel stressed over trying to care for my
4)    care receiver and still carry out my other     3            2             1             0           N/A
      responsibilities.
      I feel angry and frustrated about caring
5)                                                   3            2             1             0           N/A
      for my care receiver.
      Caring for my care receiver gives me a
      sense of satisfaction, because I am able
6)                                                   3            2             1             0           N/A
      to return some of the love he or she has
      given me.
      I am a better person as a result of
7)                                                   3            2             1             0           N/A
      caring for my care receiver.
      Caring for my care receiver negatively
8)    affects other important relationships          3            2             1             0           N/A
      with my family and friends.
      My physical health suffers because of
9)                                                   3            2             1             0           N/A
      caring for my care receiver.
      I have learned a lot by caring for my
10)                                                  3            2             1             0           N/A
      care receiver.
      I feel that I should be doing more care
11)                                                  3            2             1             0           N/A
      for my care receiver.
      Sharing the duties of caring for my care
12)   receiver has brought our family closer         3            2             1             0           N/A
      together.
      I feel that I have lost control of my life
13)   since I began caring for my care               3            2             1             0           N/A
      receiver.
      I admire my care receiver for the way he
14)                                                  3            2             1             0           N/A
      or she is handling the situation.



With permission from Winter Park Health Foundation, “As Families Grow Older” www.wphf.org.


Eldercare Partners                                                                                       Page 1 of 2
January 2009
                                                                                           www.eldercarepartners.org
                                                                                                      651-234-2262




A Caregiver Self-Assessment – Scoring Guide

The purpose of this self-assessment is to give you a general idea of the level of burden and level of benefit you
feel as a result of caring for your care receiver. There are no right, or wrong answers. Feelings can change
often based on the circumstances you are currently facing. To assess how you are feeling right now, add up your
answers below:



Record your responses for each of the                                Record your responses for each of the
questions listed below and total at the                              questions listed below and total at the
bottom:                                                              bottom:

     Question #3                                                           Question #1

     Question #4                                                           Question #2

     Question #5                                                           Question #6

     Question #8                                                           Question #7

     Question #9                                                           Question #10

     Question #11                                                          Question #12

     Question #13                                                          Question #14




     Total =                                                               Total =


This total represents the degree of burden                           This total represents the degree of benefit
you feel in caring for your care receiver at                         you feel in caring for your care receiver at
this time. There are 21 possible points.                             this time. There are 21 possible points.




Do the burdens and benefits of caring for your care receiver balance each other?

Is your scale tipped in one direction?


                                       Please contact Eldercare Partners for award winning caregiver
                                       support and geriatric care management services.

                                       Phone:         651-234-2262
                                       Address:       1645 Marthaler Lane, West St. Paul, MN 55118
                                       Website:       www.eldercarepartners.org


Eldercare Partners                                                                                        Page 2 of 2
January 2009

								
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