Caregiving Assessment

Things to Consider

Select the number (on a scale of 1 - 3) that best describes your situation for each item or issue. You can total your scores if you wish to get a big picture of the situation. Lower scores indicate less manageable situations -- situations requiring additional support beyond the primary caregiver -- and higher scores indicate situations that may be more readily managed.

The care receiver is usually:

_____ (1) Confined to the bed

_____ (2) Homebound, but not bed bound

_____ (3) Able to get about on his/her own

The care receiver is:

_____ (1) Not able to feed himself/herself

_____ (2) Able to feed himself/herself but needs supervision, coaching, and company

_____ (3) Able to come to the table for meals

The care receiver is:

_____ (1) Not able to bathe himself/herself or provide other routine care (ex: shaving,

dressing)

_____ (2) Able to take a tub bath or a shower but must have assistance and support to do so

_____ (3) Independent in bathing, grooming, and dressing

The care receiver is:

_____ (1) Not able to control his/her bowels or bladder

_____ (2) Able to control bowels and bladder but must have assistance using a bedpan or

getting to the bathroom

_____ (3) Independent in getting to the bathroom

The care receiver:

_____ (1) Requires 20 hours personal care a week

_____ (2) Requires between 10 and 20 hours personal care a week

_____ (3) Requires less than 10 hours personal care a week

The care receiver is:

_____ (1) Usually mentally confused

_____ (2) Sometimes mentally confused

_____ (3) Able to think clearly and make competent decisions

From the Primary Caregiver's Perspective

The caregiver is:

_____ (1) In frail or poor health

_____ (2) Has some limitations in activities

_____ (3) In good health and is physically active

The caregiver is:

_____ (1) Employed full-time outside the home

_____ (2) Employed part-time outside the home or has a flexible and supportive work setting

_____ (3) Not employed outside the home

The caregiver is:

_____ (1) Responsible for children or other family members

_____ (2) Responsible for no one other than the care recipient

_____ (3) Able to hire full-time assistance

The caregiver:

_____ (1) Lacks skills or confidence in providing care

_____ (2) Has adequate skills and confidence to meet home care needs

_____ (3) Can hire any needed assistance

The caregiver:

_____ (1) Has less than four hours "off duty" time each week

_____ (2) Has at least one day "off duty" each week

_____ (3) Can pursue personal interests and activities

The caregiver:

_____ (1) Will lose sleep regularly in order to complete all of the daily care needs

_____ (2) Will suffer occasional sleep deficit in order to complete all the daily care needs

_____ (3) Will be able to get regular, solid intervals of sleep and not build a sleep deficit

Scoring

Lower scores indicate less manageable situations -- situations requiring additional support beyond the primary caregiver -- and higher scores indicate situations that may be more readily managed.

Lowest possible rating score for this section: 12**

** indicates a need for significant caregiver support

Highest possible rating score for this section: 36

Your total rating score for this section: ______