An Evaluation

Filling this out will help us find the right caregiver for you. It will be confidentially sent to our office.

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	Good		Wears glasses
	Fair		Needs assistance to put glasses on
	Poor		Legally blind/low vision

	Good		Hearing device in right
	Fair		Hearing device in left
	Poor		Hearing device in both

	Independent		Minimal assistance
	Moderate assistance		Maximum assistance
	Cues/monitoring

	Independent		Minimal assistance
	Moderate assistance		Maximum assistance
	Transfer in/out Tub		Grab bars

	Brushing teeth		Denture removal/placement
	Upper dentures		Lower dentures
	Independent		Minimal assistance
	Moderate assistance		Maximum assistance
	Combing hair		Applying lotions

An Evaluation

VISION

HEARING

DRESSING

BATHING

GROOMING

MEALS/NUTRITION

TOILETING

COGNITION

AMBULATION

HOUSE KEEPING

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Experience matters

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