Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Caregiver Burnout Assessment Survey
Your information
Caregiver Name
Relationship to Care Recipient
- Spouse or partner
- Parent
- Adult child
- Other relative
- Friend
- Paid caregiver
- Other
Care Recipient's Primary Condition
Caregiving Hours Per Week
- Less than 10
- 10–20
- 21–40
- More than 40
Types of Care Provided
Emotional Burden Assessment
Social Isolation & Relationship Impact
Additional details
Financial Strain Assessment
Self-Care & Physical Health Rating
Sleep Quality & Fatigue Level
Support Resources Needed
Emergency Contact
Name
Relationship
Phone
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Caregiver Burnout Assessment Survey template from formisoft.com. formisoft.com/intake-templates/caregiver-burnout-survey