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HEALTH & SAFETY..............................................................................Yes or No

Would your home require major modifications to provide an adequate environment for your relative (heating, plumbing, laundry facilities, accessible bathrooms)

Would it be necessary to modify your home to increase safety (railings) to allow mobility

Does your relative require nursing services that are too physically difficult or demanding for you (turning, transfer to toilet)

Is your relative likely to regularly disturb the sleep of others by calling out, needing care or wandering

Is your relative likely to wander away from you or the house if left unsupervised

Is your relative likely to create safety hazards for other family members because of forgetfulness or carelessness (falling asleep while smoking, misuse of appliances)


Does your relative require someone available at all times to provide personal care

Must clothing and bed linens be changed and laundered so frequently that this becomes an excessive physical demand

Do you have other family responsibilities that could result in split loyalties and/or emotional overload


Has your relative become emotionally explosive or verbally abusive

Has your relative accused you or others of trying to kill him or her (poisoning food) or stealing money

Have you become cut off from friends and other family members because of the demands of caring for your relative

Have you given up activities and interests that are important to you because of the demands of caring for your relative


Does your relative interfere with the running of your household

Has the loss of privacy become a problem for the adult members of the household (a strain on marriage)

Is there a conflict with younger adults and adolescent family members because of the presence of your relative


Is it necessary for the family to change homes or move to another community, making continued care unrealistic

Has financial demand made continued employment or longer work hours necessary

Has a helping, supportive family member moved out of the household, increasing the burden for the remaining caregivers

Has an additional family emergency created a conflict or competition for time and energy

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