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American Medical Association Caregiver Self-Assessment Questionnaire

How are you?

Caregivers often are so concerned with caring for their relative's needs that they lose sight of their own wellbeing. Please take just a moment to answer the following questions. Once you have answered the questions, do a self-evaluation.

During the past week or so, I have

  1. Had trouble keeping my mind on what I was doing
  2. Felt that I couldn't leave my relative alone
  3. Had difficulty making decisions
  4. Felt completely overwhelmed
  5. Felt useful and needed
  6. Felt lonely
  7. Been upset that my relative has changed so much from his/her former self
  8. Felt a loss of privacy and/or personal time
  9. Been edgy or irritable
  10. Had sleep disturbed because of caring for my relative
  11. Had a crying spell(s)
  12. Felt strained between work and family responsibilities
  13. Had back pain
  14. Felt ill (headaches, stomach problems or common cold)
  15. Been satisfied with the support my family has given me
  16. Found my relative's living situation to be inconvenient or a barrier to care

On a scale of 1 to 10, with 1 being "not stressful" to 10 being "extremely stressful," please rate your current level of stress. _________

On a scale of 1 to 10, with 1 being "very healthy" to 10 being "very ill," please rate your current health compared to what it was this time last year. _________

Comments:
(Please feel free to comment or provide feedback)




Self-evaluation:

To Determine the Score:

  1. Reverse score questions 5 and 15. (For example, a "No" response should be counted as "Yes" and a "Yes" response should be counted as "No"
  2. Total the number of "Yes" responses.

To Interpret the Score:

Chances are that you are experiencing a high degree of distress:

Next steps:

Source: American Medical Association. (n.d.) Caregiver self-assessment questionnaire. Available from http://www.ama-assn.org/ama/upload/mm/36/caregivertooleng.pdf