Caregiver Stress Assessment Survey

Providing care for the needs of a loved one can be a rewarding and fulfilling experience. However, at times, it can also present challenges that can lead to feelings of being stressed or overwhelmed, which can ultimately compromise your own health and well-being.

Complete this brief questionnaire to evaluate the level of stress you are experiencing as a family caregiver.

During the past few months, have you felt:
	Yes	No
Worried about leaving your loved one at home alone?	Worried about leaving your loved one at home alone?: *
Anxious about the financial or health care decisions you are making?	Anxious about the financial or health care decisions you are making?: *
Responsible for doing everything yourself?	Responsible for doing everything yourself?: *
Inadequate or that your should be doing more for your loved one?	Inadequate or that your should be doing more for your loved one?: *
Frustrated or impatient with your loved one?	Frustrated or impatient with your loved one?: *
In denial about the changes in behavior or ability that your loved one is exhibiting?	In denial about the changes in behavior or ability that your loved one is exhibiting?: *
Deprived of sleep?	Deprived of sleep?: *
A lack of appetite?	A lack of appetite?: *
More prone to illness or pain such as headaches or backaches?	More prone to illness or pain such as headaches or backaches?: *
Unfocused on the task at-hand?	Unfocused on the task at-hand?: *
Unable to balance work and family responsibilities?	Unable to balance work and family responsibilities?: *
Withdrawn from other family members and friends?	Withdrawn from other family members and friends?: *
Unable to enjoy activities that once interested you?	Unable to enjoy activities that once interested you?: *