DIRECTIONS: Read the statements & place a check for each “yes” . Add the total of your YES answers. Your total could be as small as 0, or as large as 20.
| 1. As a caregiver, do you ever wake up in the morning & wish you had not? _____ | |
| 2. Are you afraid to admit you are beginning to dislike the person you care for? _____ | |
| 3. Sometimes do you get the urge to run away & never come back? _____ | |
| 4. Do you think about getting sick (injured) so you would be hospitalized for rest? _____ | |
| 5. Do you often have trouble going to sleep at night? _____ | |
| 6. Do you sometimes drink too much alcohol out of sheer frustration? _____ | |
| 7. Do you sometimes yell at the person you are caring for? _____ | |
| 8. Do you think the person you care for may be taking advantage of you? _____ | |
| 9. Do you think the person you care for has become indifferent to your comfort? _____ | |
| 10. Have your friends disappeared since you have become a caregiver? _____ | |
| 11. Is the care recipient occassionally jealous when you do something recreational? _____ | |
| 12. Have you realized you no longer have much to talk about with the your charge? _____ | |
| 13. Have your children &/or other relatives stopped visiting your home? _____
14. Are you eating too much, or too little? _____ |
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| 15. Do you have a lot more headaches or other physical discomforts? _____ | |
| 16. Do you have fantasies about finding someone else to spend time with? _____ | |
| 17. Do you find yourself depressed or in a bad mood these days? _____ | |
| 18. Have you begun to neglect your your personal hygiene lately? _____ | |
| 19. Do you find yourself driving more carelessly than before you
became a full-time caregiver? _____ 20. Has caregiving diminsihed your sexual realtionship? _____ 21. Do you feel stuck because of a promise or wedding vow? _____ |
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| 22. When you feel burned out, you feel guilty? _ |