Name How is caregiving impacting your work, family, life, health, and finances? What Value do you put on the following categories? How much money are you forfeiting by being a caregiver? How is caregiving impacting your relationships? Full Name * Email * Phone * Category: Worry I spend more than 5 hours a week worrying about my loved one? * 1 not often - 5 often I worry about my loved one falling? * 1 not often - 5 often I worry that my loved one with dementia is vulnerable to scammers * 1 not often - 5 often I worry about my loved one’s driving ability * 1 not often - 5 often I worry about my availability to help care for my loved one? * 1 not often - 5 often I worry when my loved one doesn’t answer their phone? * 1 not often - 5 often I worry about my loved one not taking their medication properly? * 1 not often - 5 often I worry about weight loss/poor nutrition of my loved one? * 1 not often - 5 often I worry if my loved one missed an important appointment * 1 not often - 5 often I worry about how much longer I can worry? * 1 not often - 5 often Category: Work I worry about missed career opportunities related to my absence due to caregiving? * 1 not often - 5 often My boss says I’d better get a plan together so I stop missing work? * 1 not often - 5 often I fear I will exhaust all of my vacation days for aging loved one’s medical issues. * 1 not often - 5 often I feel uncomfortable taking an actual vacation. * 1 not often - 5 often I miss project deadlines, sales quotas, important meetings, conferences due to caregiving? * 1 not often - 5 often I feel my caregiving has impacted my productivity and career growth. * 1 not often - 5 often I frequently exhaust my FMLA * 1 not often - 5 often Category: Health I have put off my own surgery because of my caregiving responsibilities * 1 not often - 5 often My health is impacted by my need to caregive. * 1 not often - 5 often I miss spending time with my own family and friends * 1 not often - 5 often I cannot do activities I enjoy, attend social events, or get together with my friends * 1 not often - 5 often I miss my own doctor appointments and check ups. * 1 not often - 5 often I feel isolated, on edge and experience changes in appetite, mood, and sleep. * 1 not often - 5 often My loved ones tell me to slow down and take care of myself * 1 not often - 5 often Category: Relationships My relationship with my spouse is strained. * 1 not often - 5 often My relationship with my aging parents is strained. * 1 not often - 5 often My relationship with my siblings is strained. * 1 not often - 5 often My friends/family tell me to seek help. * 1 not often - 5 often Category: Finances I am concerned about spending out of pocket for my aging loved ones care. * 1 not often - 5 often I am concerned about out of pocket spending on “crisis travel” (expensive airfare, hotel, rental cars) * 1 not often - 5 often I am concerned about lost income/revenue when missing work. * 1 not often - 5 often I am concerned about jeopardizing my financial health if I change my employment status to be a caregiver. * 1 not often - 5 often Total Total:
