Caregiver Responsibility Fatigue Assessment Form
Please complete this form to help us understand your experiences and challenges as a caregiver. Your responses will assist in identifying areas of support and well-being.
What is your relationship to the person you care for?
*
Parent
Spouse/Partner
Child
Sibling
Friend
Other
How many hours per week do you spend providing care?
*
Less than 10 hours
10–20 hours
21–40 hours
More than 40 hours
What type of care do you primarily provide?
*
Physical assistance (mobility, hygiene)
Emotional support
Medical management
Household tasks
Financial management
Other
How would you rate your current level of physical fatigue related to caregiving?
*
1
2
3
4
5
How would you rate your current level of emotional fatigue related to caregiving?
*
1
2
3
4
5
Please indicate how often you experience the following feelings due to caregiving responsibilities.
*
Rows
Never
Rarely
Sometimes
Often
Always
Feeling overwhelmed
1
2
3
4
5
Feeling stressed
6
7
8
9
10
Feeling isolated
11
12
13
14
15
Difficulty sleeping
16
17
18
19
20
How would you describe the availability of support from others (family, friends, community)?
*
Always available
Usually available
Sometimes available
Rarely available
Never available
How much has caregiving impacted your daily life and activities?
*
No impact
Minor impact
Moderate impact
Significant impact
Severe impact
How confident are you in your ability to cope with caregiving responsibilities?
*
Very confident
Somewhat confident
Neutral
Somewhat unconfident
Not at all confident
What is your greatest current challenge as a caregiver?
*
Submit Assessment
Should be Empty: