Dementia Caregiver Screening Tool

Are you caring for a loved one who is living with dementia? Lower Cape Fear LifeCare is here to help.

Our Memory Partners Program equips and empowers caregivers to navigate the challenges of dementia while providing wide-ranging care, resources and support for patients and their loved ones, throughout the disease’s full progression. This 14 question assessment is the first step in helping improve the lives of families challenged by dementia by providing personal support, respite care, caregiver training, and education.

1. Who do you care for?*
2. Do you live in the same household as the person you care for?
3. Do you feel that because of the time you spend with your relative that you don’t have enough time for yourself?
4. Do you feel stressed between caring for your relative and trying to meet other responsibilities (work/family)?
5. Do you feel angry when you are around your relative?
6. Do you feel that your relative currently affects your relationship with family members or friends in a negative way?
7. Do you feel strained when you are around your relative?
8. Do you feel that your health has suffered because of your involvement with your relative?
9. Do you feel that you don’t have as much privacy as you would like because of your relative?
10. Do you feel that your social life has suffered because you are caring for your relative?
11. Do you feel that you have lost control of your life since your relative’s illness?
12. Do you feel uncertain about what to do about your relative?
13. Do you feel you should be doing more for your relative?
14. Do you feel you could do a better job in caring for your relative?
Personal Information
First Name*
Last Name*
Email*
Phone*
Zip Code*
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Dementia Caregiver Screening Tool

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