Caregiver Health Quick 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 5-10 minutes to complete the check-up.Please enable JavaScript in your browser to complete this form. - Step 1 of 7Name *Email *NextCaregiver Physical HealthThis 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…TerriblePoorFairGoodExcellentI exercise _____ days in an average week.01 - 23 - 45 - 67Across one week, I average _____ hours of sleep per night.0 - 22 - 44 - 66 - 88+The 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 bitExtremelyNextCaregiver Mental and Emotional HealthThis 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 StressfulSomewhat StressfulModerately StressfulQuite StressfulExtremely StressfulDescribe 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 your life as a whole (not just the caregiving situation you are in)?No/Very Little WorrySome WorryModerate WorryQuite a bit of WorryExtreme WorryHow would you describe your ability and skills to cope and/or manage your thoughts and feelings?TerriblePoorFairGoodExcellentThe 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 BitExtremelyNextCaregiver Social and Family HealthThis 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 LonelySomewhatModeratelyQuite a BitExtremely LonelyWhat 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 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 BitExtremelyNextCaregiver Financial and Employment HealthThis 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 employment and your caregiving responsibilities:My caregiving responsibilities have affected my employment by 0 - 5% of my work life.My caregiving responsibilities have affected my employment by 5 - 25% of my work life.My caregiving responsibilities have affected my employment by 25 - 50% of my work life.My caregiving responsibilities have affected my employment by 50 - 75% of my work life.My caregiving responsibilities have affected my employment by 75 - 100% of my work life.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 BitExtremelyNextHealth of the Caregiving LandscapeThis 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....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
