Page 22 - Dementia-Care-Specialist-Toolkit

9. In general, would you say your health is:
Excellent Very good Good Fair Poor Unknown Refused

0 1 2 3 4

10. In the past month, have you felt depressed, sad, had crying spells or felt like you often needed to cry?

Never Sometimes Often* Unknown Refused
0 1 2

11. How often in the past six months, have you felt like screaming or yelling at (CR) because of the way he/she behaved?
Never Sometimes Often Unknown Refused

0 1 2

12. How often in the past six months, have you had to keep yourself from hitting or slapping (CR) because of the way he/she behaved?

Never Sometimes Often Unknown Refused
0 1 2

13. Is it hard or stressful for you to take care of basic household chores, like cleaning, yard work, or home repairs?
Never Sometimes Often Unknown Refused

0 1 2

14. Do you feel strained (ie. stressed, tense, or anxious) when you are around (CR)?

Never Rarely Sometimes Quite Often Frequently Nearly Always Unknown Refused
0 1 2 3 4 5

15. Is it hard or stressful for you to help (CR) in basic daily activities, like bathing, changing clothes, brushing teeth, or shaving?

Never Sometimes Often Unknown Refused
0 1 2

16. Providing help to (CR) has made me feel good about myself.

Disagree Disagree Neither agree Agree Agree Unknown Refused
a lot a little nor disagree a little a lot
3 2 1 0
* Mental Health referral

CR=Care recipient
Responses in Bold indicate High Risk
Responses in Italics indicate Moderate Risk

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