Caregiver Stress Test Form

Full Name *

Phone Number *

Best time to call

Email Address

Feel like you have to do it all yourself and that you should be doing more?

Yes

No

Withdraw from family, friends and activities that you used to enjoy?

Yes

No

Worry about the safety of the person you care for?

Yes

No

Feel anxious about money and health care decisions?

Yes

No

Deny the impact of the disease and its effects on your family?

Yes

No

Feel grief or sadness that your relationship with the person isn't what it used to be?

Yes

No

Get frustrated and angry when the person with dementia continually repeats things and doesn't seem to listen?

Yes

No

Have health problems that are taking a toll on you?

Yes

No

CAREGIVING CAN BE STRESSFUL