Quiz - Family Caregiver

Instructions:  Answer the 7 questions by clicking on the appropriate check box.  To total your score, click on "Step 1. Calculate."  To print your quiz, click on "Step 2. Print to PDF."  To view your results, click on "Step 3. See How You Scored on the Quiz."

To print a blank quiz, click on "Print Blank Quiz."

Date: 8/20/2017

Older Person Name:

Family Caregiver Name:

1.
Does <name of older person (NOP)> need help from someone else to do the following?





0
2.
During the last 6 months, has <NOP> had a fall that caused injuries or engaged in behavior problems such as wandering, verbal or physical disruption, or other behaviors that require supervision?

NOTE: “Injuries” means fracture or joint dislocation, head injuries resulting in loss of consciousness and hospitalization, joint injuries that led to decreased activity, internal injuries that led to hospitalization OR 3 or more of any falls
0
3.
Does <NOP> have a family member/friend give help when she/he needs it?

0
4.
(if caregiver) Do you feel overwhelmed or stressed because of the care you provide <NOP>?

0
5.
Have you/<NOP> thought about moving <NOP> to other housing?

0
6.
Does <NOP> live alone?

0
7.
Do you or your family have concerns about your memory, thinking, or ability to make decisions?
Are you:

0
TOTAL SCORE = 0