Caregiver Support Services of Omaha, NE


	Contact Us		Search Site		Home

Two-Minute Caregiver Assessment

Please answer all questions below. After completion, your results will be calculated and displayed for you.

* all survey fields are required

Caregiver Information

E-mail Address:*
State:*

Working and Caregiving

1. Are you currently working full or part time in addition to caregiving?

Full time
Part time
Not applicable

2. Caregiving takes time out of my workday?

Yes
Somewhat
Not at all

Medication Management

1. I assist my loved one with managing his/her medications.

Yes
Sometimes
Not at all

2. I understand what my loved one's medications are for, their possible side effects, and how they may interact with one another.

Yes
Somewhat
Not at all

Depression

1. I have feelings of loneliness?

Yes
Sometimes
Not at all

2. I wake up worrying about caregiving in the middle of the night.

Yes
Sometimes
Not at all

Smaller Tasks

1. I feel disorganized and could use assistance in organizing the care of my loved one.

Yes
Sometimes
Not at all

2. When I ask for help from family and/or friends I generally receive the help.

Yes
Sometimes
Not at all

Stress

1. I have emotional or physical health problems?

Yes
Sometimes
Not at all

2. Do you have frequent nights where you are not able to sleep through the night?

Yes
Sometimes
Not at all

Outsourcing

1. I am familiar with programs and/or services that may help me with caregiving?

Yes
Somewhat
Not at all

2. I have a plan in place for the future care of my loved one.

Yes
Somewhat
Not at all

Preplanning

1. I have a plan in place in case there is a sudden loss of my loved one.

Yes
Somewhat
Not at all

2. I know where to locate the necessary emergency paperwork in the case of an emergency.

Yes
Somewhat
Not at all

Music Controls

Return to Top

Print Page

Who We Are Media My Caregiver Wellness Nurse Aide Registries Training & Registration Medicare Interactive

Caregiver Support Services are members of:

Alzheimer's Foundation of America and NFCA