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Caregiver Distress Checklist

Caregiver Self-Assessment Questionnaire

How are YOU?

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

During the past week or so, I have ...

1. Had trouble keeping my mind on what I was doing.......... □ Yes □ No

2. Felt that I couldn’t leave my relative alone........... □ Yes □ No

3. Had difficulty making decisions........... □ Yes □ No

4. Felt completely overwhelmed……..... □ Yes □ No

5. Felt useful and needed........... □ Yes □ No

6. Felt lonely............ □ Yes □ No

7. Been upset that my relative has changed so much from his/her former self....... □ Yes □ No

8. Felt a loss of privacy and/or personal time........... □ Yes □ No

9. Been edgy or irritable............ □ Yes □ No

10. Had sleep disturbed because of caring for my relative............ □ Yes □ No

11. Had a crying spell(s)............. □ Yes □ No

12. Felt strained between work and family responsibilities........... □ Yes □ No

13. Had back pain........... □ Yes □ No

14. Felt ill (headaches, stomach problems or common cold)............ □ Yes □ No

15. Been satisfied with the support my family has given me............. □ Yes □ No

16. Found my relative’s living situation to be inconvenient or a barrier to care...... □ Yes □ No

17. On a scale of 1 to 10, with 1 being “not stressful” to 10 being “extremely stressful,” please rate your current level of stress. _______

18. 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.)

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

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Self-evaluation

To determine your score

1. Count up all your “Yes” responses EXCEPT do not count # 5 or 15 yet.

2. Now, look at Questions #5 and 15. If you responded “Yes” to these questions, do NOT count these with your “Yes” count. If you responded “No” to either or both questions, add these to your “Yes” count. (For example, if you had 4 “Yes” answers on the rest of the questions, and you answered “No” to question #5 and “No” to question #15, your total score would be 6.)

To interpret your response

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

  • If you answered “Yes” to either or both questions 4 and 11; or
  • If your total “Yes” score = 10 or more; or
  • If your score on question 17 is 6 or higher; or
  • If your score on question 18 is 6 or higher
  • Source: American Medical Association. All Rights Reserved

If you are having a high degree of distress

  • Consider seeing a doctor for a check-up for yourself
  • Look for some relief from caregiving (Talk to the patient’s doctor, social worker, or cancer care team about resources available in your community.)
  • Consider joining a support group for caregivers. Online and phone support is available
  • Call the American Cancer Society at 1-800-227-2345 for more information and referrals

If your distress level is low

It isn’t unusual for caregivers to have some of these problems for a short time. But they may mean that you’re at risk for higher levels of distress. When caregivers don’t attend to their own needs and allow other pressures to take over, they may lose the ability to continue to care for their loved one. Part of caring for someone else is caring for yourself.

You may want to learn more about managing caregivers’ responsibilities. You can learn more about caregiving on our Web site. You can also get ideas about healthy coping from our Coping Checklist for Caregivers.

Now what?

Asking for help can be a good thing. You may need more than one kind of help to manage caring for your loved one. See a doctor if you have serious distress, or if you can’t accomplish your day-to-day activities. We also encourage you to print out this checklist and talk it over with a doctor, nurse, social worker, or other professional on your loved one’s cancer care team.

ACS support programs reach cancer survivors and patients throughout the US. Practical advice is also available online to help caregivers manage day-to-day and cope with physical and emotional changes. At the ACS Cancer Survivors Network Web site you can trade information and experiences with other caregivers—all without leaving home.

For more information call your American Cancer Society at 1-800-227-2345.


Last Medical Review: 10/18/2011
Last Revised: 10/18/2011