Personal Caregiver Survey Adapted from Washington State s Personal Family Caregiver Survey (
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1 Personal Caregiver Survey dapted from Washington State s Personal Family Caregiver Survey ( This Survey is for unpaid primary caregivers of a family member or close friend or neighbor and is used in conjunction with one-on-one consultation with a caregiver specialist in the King County Caregiver Support Network. If you have not done so, contact any one of the providers in the King County Caregiver Support Network to learn more about the Survey and how it fits into the support and resources they offer. For provider agency names and contact information, visit or call ELDERS. Today s Date Name Day Phone Street ddress City Zip County of Residence 1. re you the person most responsible for caring for an adult, such as your spouse, partner, parent, relative or friend (or a care receiver*)? Yes No * Care receiver means any adult (18 years or older) who needs care or supervision by an unpaid caregiver. For example, a care receiver can be your spouse, partner, parent, adult child, friend, neighbor or other relative. 2. Whom do you care for? Wife Mother-in-law Brother Brother-in-law Husband Father-in-law Sister Daughter-in-law Partner Grandmother Son Son-in-law Mother Grandfather Daughter Non-relative Sister-in-law Other, please describe: Father Grandchild Personal Caregiver Survey Page 1
2 3. Instructions: The following are thoughts and feelings people sometimes experience when caring for an adult. Read through each of the statements below and indicate how much you agree or disagree with each statement by making a check in the appropriate box. Strongly a Little gree a Little gree gree Strongly a. The things I am responsible for do not fit very well with what I want to do. b. I am not always able to be the person I want to be when I am with my care receiver. c. It is difficult for me to accept all the responsibility for my care receiver. d. I am having trouble accepting the way I relate to my care receiver. e. I am not sure that I can accept any more responsibility than I have right now. f. It is difficult for me to accept the responsibilities that I now have to assume. 4. Instructions: The following are aspects of life that can change as a result of caregiving responsibilities. Please check the box that best reflects how you feel about each of the following statements (continued on page 3).. My caregiving responsibilities have: a. Caused conflicts with my care receiver. b. Decreased time I have to myself. c. Created a feeling of hopelessness. d. Given my life more meaning. e. Increased the number of unreasonable requests made by my care receiver. f. Kept me from recreational activities. Not at ll Little Moderately Lot Great Deal Personal Caregiver Survey Page 2
3 My caregiving responsibilities have: Not at ll Little Moderately Lot Great Deal g. Made me nervous. h. Made me more satisfied with my relationship with the care receiver. i. Caused me to feel that my care receiver makes demands over and above what he/she needs. j. Caused my social life to suffer. k. Depressed me. l. Given me a sense of fulfillment. m. Made me feel I was being taken advantage of by my care receiver. n. Changed my routine. o. Made me anxious. p. Left me feeling good. q. Increased attempts by my care receiver to manipulate me. r. Given me little time for friends and relatives. s. Caused me to worry. t. Made me enjoy being with my care receiver more. u. Left me with almost no time to relax. v. Made me cherish my time with my care receiver. Personal Caregiver Survey Page 3
4 5. Instructions: Please indicate how often have you felt the following during the past week? a. I was bothered by things that usually don t bother me. b. I had trouble keeping my mind on what I was doing. Rarely or none of the time (< 1 day) Some or a little of the time (1 2 days) Occasionally or a moderate amount of time (3 4 days) ll of the time (5 7 days) c. I felt depressed. d. I felt that everything I did was an effort. e. I felt hopeful about the future. f. I felt fearful. g. My sleep was restless. h. I was happy. i. I felt lonely. j. I could not get going. 6. Please indicate which of the following best describes your care receiver s memory. No Memory Problem. Memory or Cognitive Issue Suspected. Probable lzheimer s disease or other dementia is suspected, but is not medically diagnosed. Yes, lzheimer s disease or other dementia has been medically diagnosed. 7. Given your care receiver s CURRENT CONDITION, would you consider having him or her move to an out-of-home, long-term care setting? Definitely not. Probably not. Probably would. Definitely would. Does not apply-care receiver is in care facility. Personal Caregiver Survey Page 4
5 For more information about caregiver support services, visit King County Caregiver Support Network at or call ELDERS. Personal Caregiver Survey Page 5
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