The Caregiver Health Check-up

This check-up is designed to assess these four distinct areas of Caregiver Health: Physical Health, Mental & Emotional Health, Social & Family Health, and Financial & Career Health.

Getting stronger in these four areas helps caregivers on their path to becoming healthier, experiencing a greater sense of wellness, and building resilience for the days ahead.

Please allow for 5-10 minutes to complete this check-up.  A copy of your answers will be emailed to you when you are finished.

Caregiver Physical Health

This section of the checkup explores your physical health, including your diet, exercise, sleep, care for existing conditions, doctor visits, etc.

I consider the food choices I make overall to be…

• Terrible
• Poor
• Fair
• Good
• Excellent

I exercise _____ days in an average week.

• 0
• 1 - 2
• 3 - 4
• 5 - 6
• 7

Across one week, I average _____ hours of sleep per night.

• 0 - 2
• 2 - 4
• 4 - 6
• 6 - 8
• 8+

The importance I assign to my physical health is best described as...

• Not important
• Somewhat important
• Moderately important
• Quite important
• Extremely important

I consider my overall physical health to be...

• Terrible
• Poor
• Fair
• Good
• Excellent

The degree to which my overall physical health has been negatively affected by my role as a caregiver is...

• Not at all
• Some
• Moderately
• Quite a bit
• Extremely

Next --> Mental and Emotional Health

Caregiver Mental and Emotional Health

This section of the checkup explores your mental and emotional health, including questions that examine stress, guilt, respite, depression, resilience, coping skills, spiritual practices, etc.

How would you describe your life’s current stress level?

• Not at all Stressful
• Somewhat Stressful
• Moderately Stressful
• Quite Stressful
• Extremely Stressful

Describe the level of irritation, anger, or resentment you feel.

• Not at all Angry
• Somewhat Angry
• Moderately Angry
• Quite Angry
• Extremely Angry

Describe the level of sadness/depression you experience (this includes feelings of hopelessness/worthlessness).

• Not at all Sad
• Somewhat Sad
• Moderately Sad
• Quite Sad
• Extremely Sad

How much worry/anxiety do you feel for your life as a whole (not just the caregiving situation you are in)?

• No/Very Little Worry
• Some Worry
• Moderate Worry
• Quite a bit of Worry
• Extreme Worry

How would you describe your ability and skills to cope and/or manage your thoughts and feelings?

• Terrible
• Poor
• Fair
• Good
• Excellent

The importance I assign to my mental/emotional health is best described as:

• Not Important
• Somewhat Important
• Moderately Important
• Quite Important
• Extremely Important

I consider my overall mental/emotional health to be…

• Terrible
• Poor
• Fair
• Good
• Excellent

The degree to which my overall mental/emotional health has been negatively affected/disrupted by my role as a caregiver is...

• Not at All
• Some
• Moderately
• Quite a Bit
• Extremely

Next --> Social and Family Health

Caregiver Social and Family Health

This section of the checkup explores the health of your social interactions and family relationships.

How would you describe your level of loneliness/isolation in your caregiving role?

• Not at all Lonely
• Somewhat Lonely
• Moderately Lonely
• Quite a Bit Lonely
• Extremely Lonely

What is the quality of your current relationship with your significant other/spouse/partner.

• Terrible--We constantly fight and bitterly disagree about decisions and issues.
• Poor--We are not close, we disagree, but it is not constant/bitter.
• Fair--We make it work, but it’s neither warm nor cold.
• Good--We are mostly aligned and work well together, but it’s not overly warm.
• Excellent--The relationship is incredibly warm and loving, we are almost always aligned.
• N/A - No significant other/spouse/partner.

What is the “average level” relationship you have with your family members?

• Terrible--We constantly fight and bitterly disagree about decisions and issues.
• Poor--We are not close, we disagree, but it is not constant/bitter.
• Fair--We make it work, but it’s neither warm nor cold.
• Good--We are mostly aligned and work well together, but it’s not overly warm.
• Excellent--The relationship is incredibly warm and loving, we are almost always aligned.
• N/A - No other family members are directly engaged in this caregiving situation.

Considering your total level of social interactions across all groups--family, co-workers, friends, and others--what amount of social interaction do you have?

• Less than I need
• Just what I need
• More than I need

The importance I assign to my social and family health is best described as…

• Not Important
• Somewhat Important
• Moderately Important
• Quite Important
• Extremely Important

I consider my overall social interactions/health to be…

• Terrible
• Poor
• Fair
• Good
• Excellent

The degree to which my overall social interactions/health has been negatively affected/disrupted by my role as a caregiver is…

• Not at All
• Some
• Moderately
• Quite a Bit
• Extremely

Next --> Financial and Career Health

Caregiver Financial and Career Health

This section of the checkup explores your financial/employment health, including how much time is spent in your caregiving role.

As objectively as you can, select which statement best describes the amount of TIME you spend as a caregiver:

• I spend entirely too much time as a caregiver and my life is out of control because of it.
• I spend more time than I likely need to spend as a caregiver and would like to reduce those hours.
• I think I spend just about the right amount of time as a caregiver--it’s in balance and I am satisfied.
• I should spend more time than I do as a caregiver and would like to increase those hours.
• I spend entirely too little time as a caregiver--and have a strong desire to spend more time.

As objectively as you can, select which statement best describes the amount of MONEY you spend on this caregiving situation:

• I spend entirely too much money on this caregiving situation and my finances and financial future are in great danger.
• I spend more money than I likely should be spending on this caregiving situation and would like to reduce that spend.
• I think I spend just about the right amount of money on this caregiving situation; I’m satisfied.
• I should spend more money on this caregiving situation than I do, and I’d like to increase that spend.
• I spend entirely too little money on this caregiving situation and have a strong desire to spend more.

Choose the statement below that best characterizes how you think about your career and your caregiving responsibilities:

• My caregiving responsibilities have affected my career by 0 - 5%.
• My caregiving responsibilities have affected my career by 5 - 25%.
• My caregiving responsibilities have affected my career by 25 - 50%.
• My caregiving responsibilities have affected my career by 50 - 75%.
• My caregiving responsibilities have affected my career by 75 - 100%.

The degree to which my overall financial/career health has been negatively affected/disrupted by my role as a caregiver is…

• Not at All
• Some
• Moderately
• Quite a Bit
• Extremely

Next --> Caregiving Landscape

Health of the Caregiving Landscape

This section of the checkup explores the health of your “Caregiving Landscape.” The health of the care situation you are managing, including your recipient of care’s health, their housing, and the collaboration of others--as it has a direct impact on your health. The below questions explore areas of that Landscape at a general level.

The physical health, including mobility, of my care recipient is....

• Terrible
• Poor
• Fair
• Good
• Excellent

The mental and emotional health of my care recipient (including their cognitive/thinking abilities) is....

• Terrible
• Poor
• Fair
• Good
• Excellent

The health of my care recipient’s relationships with their family and other social connections is….

• Terrible
• Poor
• Fair
• Good
• Excellent

My care recipient’s sense of identity and purpose is….

• Terrible
• Poor
• Fair
• Good
• Excellent

The financial and legal health of my care recipient is....

• Terrible
• Poor
• Fair
• Good
• Excellent

The condition of my care recipient’s housing and transportation is….

• Terrible
• Poor
• Fair
• Good
• Excellent

The availability, balance, and quality of my care recipient’s external services and outside help is….

• Terrible
• Poor
• Fair
• Good
• Excellent

The degree to which my care recipient’s situation is planned, monitored, and coordinated is….

• Terrible
• Poor
• Fair
• Good
• Excellent

Next --> Demographics (Optional Information)

DEMOGRAPHICS

(Optional -- Please fill out all fields that you are comfortable sharing with us; we will use this information to guide course and service creation.)

Name

Age

GenderMaleMaleFemaleNon-BinaryPrefer not to say

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Level of EducationHigh SchoolHigh SchoolSome CollegeAssociate'sBachelor'sMaster'sPhD

Employment:

• Part-Time
• Full-Time
• Self-Employed
• No Work

Number of Children

Children's Ages, if applicable:

Do children live with you?

• Yes
• No
• N/A

Recipient of Care Gender:MaleMaleFemalePrefer not to say

Recipient of Care Age:

Recipient of Care Relationship -- The recipient of care is my: MotherMotherFatherGrandmotherGrandfatherSpouse/Significant OtherBrotherSisterAuntUncleSonDaughterOther

Do you live with the recipient of care?

• Yes
• No

If yes:

• Your Home
• Other

Other Location

Email - Please enter your best email for sending a copy of your check-up. *

Submit