* 1. During your time as a caregiver, have you noticed any of these changes in yourself and/or your life?

  Very Insignificant Insignificant Neutral Significant Very Significant
Change in eating habits
Change in sleeping habits
Change in usual type/amount of recreation
Change in work hours/conditions
Change in living conditions
Change in health/behavior of family member
Change in personal habits
Change in social activities
Change in friendships
Needing to make decisions regarding immediate future
Change in finances

* 2. How are the factors below influencing your stress level in your daily life?

  Very Often Often Occasionally Rarely Never
Misplacing or losing things
Troubling thoughts about your future
Thoughts about death
Health of a family member
Not enough money for housing
Concerns about money for emergencies
Smoking too much
Use of alcohol
Too many responsibilities
Planning meals
Concerns about the meaning of life
Trouble relaxing
Concerns about medical treatment
Filling out forms
Rising prices of common goods
Not getting enough sleep
Not enough time to get things done
Not enough energy
Inability to express yourself
Financial security
Transportation problems
Not enough time for recreation
Not enough money for health care
Feeling lonely
Concerns about retirement
Concerns about job security
Trouble making decisions
Physical appearance
Concerns about health in general
Social isolation
Preparing meals
Declining physical abilities
Not getting enough rest
Too many things to do
Watching too much television
Feeling conflicted about what to do

* 3. How do you relate to the following statements?

  Strongly Disagree Disagree Neutral Agree Strongly Agree
I wake up energized and looking forward to the day
I would describe myself as an optimist
I look at challenges as opportunities
I am okay with not being in control all the time
I consider myself resilient & able to bounce back from challenges
I am an organized
I am flexible with daily life
I am described as always being able to see the positive in life

* 4. How do you identify with each of the following statements?

  Strongly Disagree Disagree Neutral Agree Strongly Agree
See the positive in every situation
Spend time worrying about future events
Spend time thinking about past regrets
Look at failure as an opportunity for growth
Count my blessings everyday
Expect very little from other people
Have an ability to modify my expectations to avoid feeling as if I’ve failed
Am scared to confront life’s challenges
Have many fear based thoughts
Can adapt to situations easily and positively
Am able to pinpoint obstacles that might be in the way of a goal
Don’t try to control people or circumstances that are completely out of my control
Am continually disappointed in others

* 5. Thinking about the past month compared to the onset of the caregiving period, rate the following statements

  Things have gotten much worse Somewhat worse Neutral Improved a little Improved a lot
Feeling rested
Ability to sleep through the night
Ability to have time for self
Energy level
Feeling overwhelmed
Feeling upset
Feeling calm or relaxed
Things have been running smoothly
Feelings of anger
Ability to understand care recipient’s behavior
Sense of control over care recipient’s problems
Ability to manage day-to-day caregiving
Ability to handle new caregiving problems

* 6. How do you assess your ability to do the following?

  Very Poorly Poorly Neutral Good Great
Express feelings about the illness
Maintain hope and optimism
Talk openly and honestly with care recipient
Talk openly about death and dying
Deal with care recipient’s expression of negative emotions
Deal with criticism from others
Ask for help
Seek social support from friends
Seek support from family
Letting go of things I can’t control
Continue my own self-care practices since the caregiving period began (i.e. exercise, sleep)
Continue to engage in personal activities that bring me joy
Dealing with feelings of helplessness
Feel free to ask physicians and nurses questions
Understand the medical options
Understand the medical knowledge from nurses and doctors
Ability to manage all the information

* 7. How have each of the following served you during the caregiving period?

  None Comfort Guidance Physical Assistance Emotional Support Maintaining a sense of balance and normalcy in life
Social support (friends)
Family support
Professional support (therapy, support groups)
Religious beliefs and community
Cultural beliefs about death and dying
Taking care of myself
Going to work

* 8. Do you feel that you have the emotional support and ability to handle the following situations?

  Strongly Disagree Disagree Neutral Agree Strongly Disagree
Witnessing the care recipient in pain or discomfort
Witnessing the care recipient unable to eat or swallow
Witnessing the care recipient vomiting
Witnessing the care recipient with insomnia or sleeplessness
Witnessing the care recipient falling or fainting
Witnessing the care recipient in confusion
Maintaining a close relationship with the care recipient
Listening to the care recipient to better learn how to care for them
Being able to notice the happy moments
Helping the care recipient express their own emotions and feelings
Provide emotional support for the care recipient

* 9. How do you feel about the following statements?

  Strongly Disagree Disagree Neutral Agree Strongly Agree
I feel tense or wound up
I get a sort of frightened feeling as if something bad is about to happen
Worrying thoughts go through my mind
I can sit at ease and feel relaxed
I get a sort of frightened feeling like butterflies in the stomach
I feel restless and have to be on the move
I get sudden feelings of panic
I still enjoy the things I used to enjoy
I can laugh and see the funny side of things
I feel cheerful
I feel as if I am slowed down
I have lost interest in my appearance
I look forward with enjoyment to things
I can enjoy a good book or radio or TV show