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Caregiving Assessment

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Things to Consider

Select the numbered statement (statements are rated on a scale of 1 - 3) that best describes your situation for each item below. You can total your scores by adding the numbers of the selected statement. This will give you a big picture of the caregiving situation. Lower scores indicate situations that are less manageable -- that is situations that require additional support beyond that provided by the primary caregiver. Higher scores indicate situations that may be more readily managed.

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The care receiver is usually:

_____ (1) Confined to the bed

_____ (2) Homebound, but not bed bound

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

The care receiver is:

_____ (1) Not able to feed himself or herself

_____ (2) Able to feed himself or 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 or herself or provide other routine care (for example, shaving or

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 or 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:

_____ (1) Is in frail or poor health

_____ (2) Has some limitations in activities

_____ (3) Is 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

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