Elderly Home Care Evaluation Form

Caregiver Name Client Name Date of Evaluation Punctuality Excellent Good Fair Poor Attitude Excellent Good Fair Poor Professionalism Excellent Good Fair Poor Communication Skills Excellent Good Fair Poor Personal Care (bathing, grooming, etc.) Excellent Good Fair Poor Medication Management Excellent Good Fair Poor Meal Preparation Excellent Good Fair Poor Home Cleanliness Excellent Good Fair Poor Assistance with Other Tasks Caregiver Strengths Areas for Improvement Additional Comments