Caregiver Health Complete Check-up This check-up is provided to help you monitor your life as a caregiver. You can use these answers to assess what areas you could improve on and as conversation starters with others to make changes and find help. Please allow for 20-30 minutes to complete the assessment.Please enable JavaScript in your browser to complete this form. - Step 1 of 7Name *Email *NextCaregiver Physical HealthThis section of the assessment 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…TerriblePoorFairGoodExcellentI consider the amount of food I consume to be...Less than I needJust what I needMore than I need In the past week, the degree to which my diet / eating has been negatively affected by my role as a caregiver is…Not at allSomeModeratelyQuite a bitExtremelyI consider the amount of activity I get each day to be…Less than I needJust what I needMore than I needI exercise _____ days in an average week.01 - 23 - 45 - 67In the past week, the degree to which my activity / exercise has been negatively affected by my role as a caregiver is... Not at allSomeModeratelyQuite a bitExtremelyI consider my physical flexibility to be….TerriblePoorFairGoodExcellentI consider my weight-management to be…TerriblePoorFairGoodExcellentI consider my mobility (ability to walk and move independently) to be….TerriblePoorFairGoodExcellentAcross one week, I average _____ hours of sleep per night.0 - 22 - 44 - 66 - 88+On an average day, I report my average level of alertness/sleepiness to be…Very sleepySleepyNeitherAlertVery AlertIn the past week, the degree to which my sleep has been negatively affected by my role as a caregiver is…Not at allSomeModeratelyQuite a bitExtremelyI take ______ (number) maintenance medications (on a regular basis).01234+My compliance with taking prescribed medication is...N/ATerriblePoorFairGoodExcellentRegarding the treatment of any known diagnosed conditions, my self-care (not considering medication) is... N/ATerriblePoorFairGoodExcellentThroughout an average week, what is the level (include a rating of frequency) of physical pain you experience? No pain/Very little painSome painModerate painQuite a bit of painExtreme painMy contact with physicians and other healthcare / fitness providers who monitor my physical health is…Less than I needJust what I needMore than I needThe importance I assign to my physical health is best described as... Not importantSomewhat importantModerately importantQuite importantExtremely importantI consider my overall physical health to be... TerriblePoorFairGoodExcellentThe degree to which my overall physical health has been negatively affected by my role as a caregiver is... Not at allSomeModeratelyQuite a bitExtremelyMy attention to and plan for the future of my physical health is...TerriblePoorFairGoodExcellentNextCaregiver Mental and Emotional HealthThis section of the assessment explores your mental and emotional health, including questions that examine stress, guilt, respite, depression, resilience, coping skills, spiritual practices, etc.How much time do you take for respite (include any type of personal time for rest (other than nighttime sleep), relief, recovery, recreation, meditation)?Less than 2 hours/week2 - 5 hours/week5 - 10 hours/week10 - 15 hours/week15+ hours/weekHow would you describe your life’s current stress level? Not at all StressfulSomewhat StressfulModerately StressfulQuite StressfulExtremely StressfulDuring the past week have you felt completely overwhelmed? YesNoDuring the past week have you had a crying spell?YesNoDescribe the level of irritation, anger, or resentment you feel.Not at all AngrySomewhat Moderately Quite Extremely AngryDescribe the level of sadness/depression you experience (this includes feelings of hopelessness/worthlessness).Not at all SadSomewhat Moderately Quite Extremely SadHow much worry/anxiety do you feel for the caregiving situation you are in (including worry/anxiety about the person receiving your care)?No/Very Little WorrySome WorryModerate WorryQuite a bit of WorryExtreme WorryHow much worry/anxiety do you feel for your life as a whole (not just the caregiving situation you are in)?No/Very Little WorrySome WorryModerate WorryQuite a bit of WorryExtreme WorrySelect the statement below that best describes the burden/load you feel from your caregiving role.I feel no or very little burden.I feel some burden, but it's quite manageable.I feel a moderate amount of burden, but if I work hard, I can achieve balance.I feel quite a bit of burden; therefore, other parts of my life are suffering.I feel extremely burdened; I do not have a minute's break from caregiving responsibilities.What level of guilt, if any, do you feel in your caregiving role?I have no to very little guilt about my caregiving responsibilities.I feel some guilt, but it doesn’t plague me.I feel a moderate amount of guilt, but I can manage/cope with the feelings to find peace.I feel quite a bit of guilt; it drives me to work too hard and worry too much.I feel an extreme amount of guilt, usually every day. It is destroying my feelings of self-worth.To what extent do you find meaning, satisfaction and purpose in life because of your caregiving role?I find no or very little meaning, satisfaction, and purpose in life because of my caregiving role.I find some meaning, satisfaction, and purpose in life because of my caregiving role.I find moderate meaning, satisfaction, and purpose in life because of my caregiving role.I find quite a bit of meaning, satisfaction, and purpose in life because of my caregiving role.I find an extreme amount of meaning, satisfaction, and purpose in life because of my caregiving role.How has your ability to make decisions and stay focused been negatively affected by your role as a caregiver?Not at AllSomeModeratelyQuite a BitExtremelyHow would you describe your ability and skills to cope and/or manage your thoughts and feelings?TerriblePoorFairGoodExcellentHow much does spirituality/religion contribute to your current situation and life?I do not affiliate with/use any spiritual practice/religious tradition.Spiritual/religious practice plays a small role in my life.Spiritual/religious practice plays a moderate role in my life.Spiritual/religious practice plays a significant role in my life.Everything I do is grounded in and filtered through a lens of spiritual/religious practice.My contact with mental/emotional/spiritual-health providers (such as therapists, psychologists and pastors) who monitor my emotional/mental/spiritual health is…Less than I needJust what I needMore than I needThe importance I assign to my mental/emotional health is best described as:Not ImportantSomewhat ImportantModerately ImportantQuite ImportantExtremely ImportantI consider my overall mental/emotional health to be…TerriblePoorFairGoodExcellentThe degree to which my overall mental/emotional health has been negatively affected/disrupted by my role as a caregiver is... Not at AllSomeModeratelyQuite a BitExtremelyMy attention to and plan for the future of my mental/emotional health is... TerriblePoorFairGoodExcellentNextCaregiver Social and Family HealthThis section of the assessment 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 LonelySomewhatModeratelyQuite a BitExtremely LonelyDescribe your relationship with the recipient of your care.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.Realizing that individual relationships can vary widely, what is the “average level” relationship you have with other family members who ARE directly engaged in the caregiving situation.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.What is the “average level” relationship you have with family members who are NOT directly engaged in the caregiving situation.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.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.If you have children, what is your “average level” of relationship with them as a group?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 children.If you work, part-time or full-time, what is your level of social interaction with work colleagues?No - Very little social engagementSome social engagement Moderate social engagementQuite a bit of social engagementExtreme amount of social engagementving, we are almost always aligned.N/A - I do not work nor do I have work colleaguesConsider other communities/groups you are part of (religious, neighborhood, dinner groups, community causes, etc.), What is your level of social interaction with these communities?No - Very little social engagementSome social engagement Moderate social engagementQuite a bit of social engagementExtreme amount of social engagementving, we are almost always aligned.N/A - I do not have relationships with any of these kinds of groupsConsidering your total level of social interactions across all groups, what amount of social interaction do you have? Less than I needJust what I needMore than I needThe importance I assign to my social and family health is best described as…Not ImportantSomewhat ImportantModerately ImportantQuite ImportantExtremely ImportantI consider my overall social interactions/health to be…TerriblePoorFairGoodExcellentThe degree to which my overall social interactions/health has been negatively affected/disrupted by my role as a caregiver is…Not at AllSomeModeratelyQuite a BitExtremelyMy attention to and plan for the future of my social interactions/health is...TerriblePoorFairGoodExcellentNextCaregiver Financial and Employment HealthThis section of the assessment explores your financial/employment health, including how much time is spent in your caregiving role.What is the average number of hours per DAY you spend fulfilling caregiving responsibilities?What is the average number of hours per WEEK you spend fulfilling caregiving responsibilities?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.What is the average amount of money you spend per week because of your caregiving responsibilities?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 employment and your caregiving responsibilities: (Consider modifications to your employment environment/location, hours worked, decisions about promotions, job changes, etc.)I have made a few modifications to my employment because of my caregiving, but nothing drastic-my caregiving situation has affected 5-20% of my work life.I have made several changes to my employment situation--a few significant changes, because of my role as a caregiver. My caregiving situation has affected 25-50% of my work life.I have made a lot of modifications to my employment situation (affecting 50-75% of my work life) because of my caregiving responsibilities. I’ve chosen different hours, different positions, and different jobs--often at a sacrifice, to accommodate my caregiving responsibilities.Everything about my employment situation would be different if it were not for my caregiving responsibilities--I have made tremendous sacrifices and tradeoffs to accommodate my caregiving (affecting 75-100% of my work life). I would work different hours, may not have quit/modified my job, perhaps would work in a different industry with a different company, work in a different city--the trajectory of my career would look very different. How willing are you to/comfortable are you in talk(ing) with your employer about your caregiving situation?N/A - I do not have an employerNot at all willing/comfortableSomewhatModeratelyQuiteExtremely willing/comfortableWhich of the following people at work have you told about your caregiving situation? (Select all that apply)N/A - I do not workMy immediate supervisorMy direct reportsHuman resourcesOther managementOther co-workersI have not told anyone at work about my caregiving situationHow supportive is your employer of your caregiving responsibilities?N/A - I do not have an employerNot at allSomewhatModeratelyQuiteExtremelyWhat kinds of programs / accommodations does your employer provide for your caregiving role/situation? (Select all that apply)N/A - I am not employedNoneLeave of Absence programFMLA (Family Medical Leave Act)Telecommuting or flexible working/flextime accommodationsCaregiving resources (online, helpline, specific counseling)Employee wellness programsEmployee assistance/education programs (EAP)Mental health / counseling servicesOtherHave you experienced adverse employment action as a result of your caregiving duties? N/A - I am not employedNoYes - Describe the adverse action in the following text box.Adverse employment action: The degree to which my overall financial/employment condition/health has been negatively affected/disrupted by my role as a caregiver is…Not at AllSomeModeratelyQuite a BitExtremelyMy attention to and plan for the future of my financial/employment condition/health is...TerriblePoorFairGoodExcellentNextHealth of the Caregiving LandscapeThis section of the assessment 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....TerriblePoorFairGoodExcellentThe mental and emotional health of my care recipient (including their cognitive/thinking abilities) is....TerriblePoorFairGoodExcellentThe health of my care recipient’s relationships with their family and other social connections is….TerriblePoorFairGoodExcellentMy care recipient’s sense of identity and purpose is….TerriblePoorFairGoodExcellentThe financial and legal health of my care recipient is....TerriblePoorFairGoodExcellentThe condition of my care recipient’s housing and transportation is….TerriblePoorFairGoodExcellentThe availability, balance, and quality of my care recipient’s external services and outside help is….TerriblePoorFairGoodExcellentThe degree to which my care recipient’s situation is planned, monitored, and coordinated is…. TerriblePoorFairGoodExcellentNextDEMOGRAPHICS(Optional -- Please fill out all fields that you are comfortable sharing with us; we will use this information to guide course and service creation.)NameAgeGenderMaleMaleFemaleNon-BinaryPrefer not to sayAddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLevel of EducationHigh SchoolHigh SchoolSome CollegeAssociate'sBachelor'sMaster'sPhDEmployment:Part-TimeFull-TimeSelf-EmployedNo WorkNumber of ChildrenChildren's Ages, if applicable:Do children live with you? YesNoN/ARecipient of Care Gender:MaleMaleFemalePrefer not to sayRecipient of Care Age:Recipient of Care Relationship -- The recipient of care is my: MotherMotherFatherGrandmotherGrandfatherSpouse/Significant OtherBrotherSisterAuntUncleSonDaughterOtherDo you live with the recipient of care?YesNoIf yes:Your HomeOtherOther LocationNext
