Caregiver Questionnaire
Developed with resources including: Family Caregiver Alliance
(http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1695.), and from
the American Family Physician (6/1/11) (http://www.aafp.org/afp/2011/0601/p1322.html ).
Please use this to prompt discussions with the care recipient’s support system and health care team,
and yours, as needed.
Date _____________________
Caregiver: Name, DOB, relationship to care recipient.
Care Recipient(s): Name, DOB. Where living? With whom?
Other Caregiver(s): Name, caregiving roles. Other?
How long have you been caregiver? Has the responsibility changed? (see below as well)
Where do you live and with whom?
How much time do you need to allot for caregiving daily/weekly?
What are other responsibilities? (Work, other caregiving, etc.) How much time do these take?
What are the Care recipient’s needs?
What Activities of Daily Living (ADLs) need help? Dressing, feeding, transfers & ambulation,
bathing, bowel and bladder care, etc.
What Instrumental ADLs need help? Driving, shopping, managing finances, housework,
telephone/communication, etc.
Does the Care recipient need help taking medications? To do self management? (Check
Blood Pressure, Blood Sugar, do Wound Care, etc.)
Does the recipient have Mental Health issues (depression, anxiety, etc), Memory,
or Behavioral problems? How severe? How are these handled?
How are you the Caregiver doing?
How do rate your own health? (good, fair, bad, etc)
How often in the past 6-12 months have you seen someone for health problems? Have
physical and/or emotional health problems worsened as a result of caregiving?
How often do you get a full night’s sleep?
Do you have a social support network or do you feel isolated?
Do you have any work-related difficulties due to the caregiving role?
What has been the financial strain, if any, due to the caregiving role?
Were you willing to assume the caregiver role? Is the care recipient willing to accept care?
How often do you feel anxious or angry when around the care recipient?
How would you rate the quality of your family relationships? How much disagreement has
there been with other family members over care issues? Has the need for caregiving
brought the family closer together?
What good things have happened to you – new skills, closer relations, etc, as Caregiver?
What needs do you have as Caregiver – training, information, other?