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CAREGIVER INFORMATION

FIRST NAME:*  LAST NAME:*  E-MAIL ADDRESS:*  PHONE NUMBER:*  FAX NUMBER:  ORGANIZATION:  TITLE:  ADDRESS 1:  ADDRESS 2:  CITY:  STATE:  ZIP CODE:

PLEASE ANSWER ALL QUESTIONS (Questions courtesy of AOA)

1.  Are you physically able to handle the tasks of caregiving? Seldom Sometimes Often Usually Always 2.  Do you feel you are emotionally able to handle the stress of caregiving? Seldom Sometimes Often Usually Always 3.  Are you able to handle routine household chores in addition to caregiving? Seldom Sometimes Often Usually Always 4.  Does your home lend itself to the caregiving tasks you must perform? Seldom Sometimes Often Usually Always 5.  Do you feel you adequately use family support? Seldom Sometimes Often Usually Always 6.  Are you able to determine the difference between essential and non-essential caregiving tasks? Seldom Sometimes Often Usually Always 7.  Do you have any hobbies or social activities outside of work? Seldom Sometimes Often Usually Always 8.  Do you feel that someone other than yourself can provide care for your loved one? Seldom Sometimes Often Usually Always 9.  Do you have access to transportation? Seldom Sometimes Often Usually Always