Scoring and next steps

This questionnaire is meant to serve as a guide only, to assist physicians to help family members providing ongoing care to the chronically ill and disabled. To start, download and print a version of the questionnaire below and give it to your patient/caregiver to fill out.  

• (English)  (PDF, 60KB, requires Adobe® Reader®)
• (Spanish)  (PDF, 66KB)

Determining the score

• Reverse score questions 5 and 15  (For example, a "No" response should be counted as "Yes" and a "Yes" response should be counted as "No".)       
• Total the number of "yes" responses.

Interpreting the score

A high degree of distress is likely:

• If the total "Yes" score = 10 or more.       
• If the score on Question 17 (perceived stress) is 6 or higher.       
• If the score on Question 18 (perceived health) is 6 or higher.       
• If the answers are "Yes" to any of the following: Q1 (distractibility), Q4 (overwhelmed), Q9 (irritability), Q10 (sleeplessness), Q11 (crying spells), Q13 (back pain), Q14 (illness).

Next steps

Any "yes" responses to the questions on the Caregiver Self-assessment Questionnaire suggest that:

• The caregiver needs further assessment to determine the need for counseling/intervention.          
• The caregiver might benefit from a medical check-up or referral to their personal physician (suggest they take the questionnaire to show).          
• The caregiver might benefit from joining a support group.          
• The caregiver be encouraged to arrange some relief from caregiving.          
• The physician discuss available community resources and refer as appropriate.          
• The physician consider a referral to social services.