Ask Emma - Caregiver Wellness Assessment
"Ask Emma" Caregiver Wellness Tool
Please select the single statement that most closely represents the reason for your visit today.
Once you have made your selection. Please proceed to the remaining questions. You are invited to answer each of the questions honestly keeping in mind that there are no right or wrong answers. Your answers are completely confidential and your information will not be shared. Thank You!
Occupational Wellness
1. I have a clear understanding of my workplace employee assistance program.
2. I am preoccupied with caregiving responsibilities while I am at work.
3. Thinking about the mental demands of your job, how do you rate your current ability to meet those demands?
Physical Wellness
1. I exercise on a regular basis, participate in physical activity without bodily pain, and am at a healthy weight; my blood pressure is controlled; and my alcohol consumption is limited.
2. I find that I do not get adequate sleep and do not feel fully rested after sleep.
3. I do not smoke and my alcohol consumption is limited.
Psychological Wellness
1. I am fully able to experience (feel) a wide range of feelings such as joy, excitement, happiness, peacefulness, fear, anger, sadness, and hopelessness.
2. I live life one day at a time and donít really think about the future.
3. I am an active person in carrying out the plans I set for myself and my loved one.
Intellectual Wellness
1. I actively seek education to improve care for my loved one and apply what I have learned to improve the health and wellness of myself and my loved one.
2. If asked by a health care professional, I would not know how to relay what is needed for my loved one.
3. I really enjoy a task that involves coming up with new solutions to problems.
Social Well-being
1. I am satisfied with the number and quality of social supports available from family, friends, church and the community.
2. Despite the fact that I have caregiving responsibilities, I continue to have contact with friends at the same level as I did in the past.
3. My loved one and I are unable to spend time apart to pursue our individual interests.
Spiritual Well-being
1. I am able to take time away from caregiving to attend to my spiritual needs.
2. I am experiencing a sense of inner peace and am able to see the positive things in life.
3. Lately I have self-doubts about and constantly feel as though I need to prove myself.
1. When necessary, I take the initiative in looking for services for myself and my loved one.
2. I am hesitant to make changes regarding the services my loved one needs, even when I am not pleased with a care or service provider.
3. I make sure that the rest of the healthcare team clearly understands my views about how to provide the services my loved one needs.
1. I am able to adjust and adapt in a healthy and flexible way to the ever-changing roles associated with caring for my loved one.
2. I think it is important to have new experiences that challenge how I think about myself and the world.
3. I do not enjoy being in new situations that require me to change my old familiar ways of doing things.
Financial Wellness
1. I have access to adequate resources to pay for the care and needs of my loved one, my family and myself.
2. I am not compensated a salary as a caregiver nor do I have funds allocated to go into my retirement account.
3. The amount of control I have over my financial situation has changed for the worst in the last year.
Caregiver Information
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