Is This Right for You Section - Test

Blank Form (#3)

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1/12

How often do you get a good night's sleep (seven or more hours)?

Every day

Often

Sometimes

Seldom or never

2/12

How often do you keep up with leisure activities that you enjoyed before caregiving?

Every day

Often

Sometimes

Seldom or never

3/12

How often do you feel irritable or lose your temper with others?

Seldom or never

Sometimes

Often

Every day

4/12

How often do you feel happy?

Every day

Sometimes

Often

Seldom or never

5/12

How often do you find it difficult to concentrate?

Often

Seldom or never

Every day

Sometimes

6/12

How often do you need a cigarette(s) or more than two cups of coffee to make it through the day?

Seldom or never

Often

Every day

Sometimes

7/12

How often do you lack the energy to cook, clean, and take care of everyday basics?

Every day

Sometimes

Often

Seldom or never

8/12

How often do you feel hopeless about the future?

Seldom or never

Often

Sometimes

Every day

9/12

How often are you able to relax without the use of alcohol or prescription sedatives?

Every day

Sometimes

Often

Seldom or never

10/12

How often do you feel overwhelmed by all you have to do?

Every day

Sometimes

Often

Seldom or never

11/12

How often has someone criticized your caregiving or suggested you're burning out?

Every day

Sometimes

Often

Seldom or never

12/12

How often do you feel that someone is looking after or caring for you?

Seldom or never

Every day

Often

Sometimes

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Your First Step to Expert Care

Name

Mobile Number

Email ID

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Type Message

Your First Step to Expert Care

caregiver

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1/13

Do you often feel overwhelmed, anxious, or helpless?

Yes

No

2/13

Have you experienced mood swings, irritability, or sudden sadness?

Yes

No

3/13

Do you feel emotionally drained or numb at the end of the day?

Yes

No

4/13

Are you sleeping less than 6 hours or experiencing poor sleep quality?

Yes

No

5/13

Do you feel physically exhausted, even after resting?

Yes

No

6/13

Have you developed frequent headaches, body aches, or digestion issues?

Yes

No

7/13

Do you find it hard to concentrate, make decisions, or stay organized?

Yes

No

8/13

Do you feel like you're constantly “on edge” or tense?

Yes

No

9/13

Have you stopped doing things you enjoy (hobbies, social outings, exercise)?

Yes

No

10/13

Do you struggle to make time for your own medical appointments or self-care?

Yes

No

11/13

Do you feel guilty taking breaks or asking others for help?

Yes

No

12/13

Do you feel isolated or that no one truly understands what you’re going through?

Yes

No

13/13

Has caregiving impacted your relationship with friends, family, or partner?

Yes

No

Tagline - Assessment Result will be sent to you by mail

cognitive

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1/10

Forget names of close friends or family members often

Yes

No

2/10

Frequently misplace items (keys, glasses, wallet) and struggle to find them

Yes

No

3/10

Get confused about the day, date, or time of day?

Yes

No

4/10

Find yourself lost in a familiar place?

Yes

No

5/10

Struggle to find the right words while speaking or forget what you were saying mid-sentence?

Yes

No

6/10

Repeat the same questions or stories during a conversation?

Yes

No

7/10

Have difficulty managing finances, appointments, or medications lately?

Yes

No

8/10

Need more help with daily tasks (cooking, shopping, handling phone calls) than you used to?

Yes

No

9/10

Have become more withdrawn, anxious, irritable, or suspicious than before?

Yes

No

10/10

Have friends or family noticed changes in your behaviour or personality?

Yes

No

Tagline - Assessment Result will be sent to you by mail