Carer Questionnaire (Zarit Burden Interview)

This form is for your appointment with Dr Jha. It is not checked out of hours, so please don’t use it for anything urgent: call 999 in an emergency, or NHS 111 or your GP for other urgent problems.

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This questionnaire is for the relative, friend or carer who looks after the patient. The statements reflect how people sometimes feel when taking care of another person. For each one, choose how often you feel that way. There are no right or wrong answers. It takes about 5–10 minutes.

About you

Your full name *

Your relationship to the patient *--- Select ---Husband, wife or partnerSon or daughterOther relativeFriendPaid carerOther

About the person you care for

Patient full name *

Patient date of birth *

For example 12/03/1941

Questions

1. Do you feel that your relative asks for more help than he or she needs? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

2. Do you feel that because of the time you spend with your relative you do not have enough time for yourself? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

3. Do you feel stressed between caring for your relative and trying to meet other responsibilities for your family or work? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

4. Do you feel embarrassed over your relative's behaviour? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

5. Do you feel angry when you are around your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

caring relationship that

6. Do you feel that your relative currently affects your relationship with other family members or friends in a negative way? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

7. Are you afraid what the future holds for your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

8. Do you feel your relative is dependent upon you? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

9. Do you feel strained when you are around your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

10. Do you feel your health has suffered because of your involvement with your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

11. Do you feel that you do not have as much privacy as you would like because of your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

12. Do you feel that your social life has suffered because you are caring for your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

13. Do you feel uncomfortable about having friends over because of your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

14. Do you feel that your relative seems to expect you to take care of him or her as if you were the only one he or she could depend on? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

15. Do you feel that you do not have enough money to care for your relative in addition to the rest of your expenses? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

16. Do you feel that you will be unable to take care of your relative much longer? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

17. Do you feel that you have lost control of your life since your relative's illness? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

18. Do you wish you could just leave the care of your relative to someone else? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

19. Do you feel uncertain about what to do about your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

20. Do you feel that you should be doing more for your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

21. Do you feel you could do a better job in caring for your relative? *

• Never
• Rarely
• Sometimes
• Quite frequently
• Nearly always

22. Overall, how burdened do you feel in caring for your relative? *

• Not at all
• A little
• Moderately
• Quite a bit
• Extremely

Consent *

• I confirm that the information provided is accurate to the best of my knowledge.
• I consent to this information being used for clinical assessment and stored securely in accordance with data protection regulations.

Submit

Your answers are stored securely on this website for Dr Jha. They are copied into your clinical record and deleted from the website within 90 days. Privacy notice

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