BATHROOM PLANNING

FORM 1: GETTING TO KNOW YOUR CLIENT

Use these questions to get general ideas about your client’s preferences, and then as a check to make sure you have the specific details needed.

Features

Name: / Age:
Height: / Weight: / Handedness: Right Left
Special needs or concerns:
Name: / Age:
Height: / Weight: / Handedness: Right Left
Special needs or concerns:
Name: / Age:
Height: / Weight: / Handedness: Right Left
Special needs or concerns:
Name: / Age:
Height: / Weight: / Handedness: Right Left
Special needs or concerns:
Name: / Age:
Height: / Weight: / Handedness: Right Left
Special needs or concerns:

FORM 1: GETTING TO KNOW YOUR CLIENT (CONTINUED)

2. Anthropometrical Information

FORM 1: GETTING TO KNOW YOUR CLIENT (CONTINUED)

3. Reach and Grasp Profile

4. Physical Profile

Physical characteristic(s) affecting activities in the bathroom:
  1. Sight:

Do you wear glasses for: Reading Distance
Are you taking medications that affect your sight?
Are you sensitive to light?
  1. Hearing:

What issues regarding your hearing will affect your activities in the Bathroom?
  1. Tactile/Touch:

Can you feel hot and cold?
  1. Taste/Smell:

What issues regarding your sense of taste or smell will affect your activities in the bathroom?
  1. Strength and Function:

What can you lift? / Carry?
Do you have more strength on one side than the other?
Do you use both hands fully? / Palms only?
How is your grip?
Left side? / Right side?
  1. Balance, Mobility and Assistance:

How is your balance:Standing? / Bending?
Does your mobility or balance vary by time of day?
Does an assistant help you: Sometimes? / All the time?
What adaptive equipment do you use?
  1. Prognosis: Is your condition stable? Is further deterioration anticipated? Is improvement anticipated?

  1. Other Physical Concerns:

  1. Special Safety Concerns:

5. Mobility Aids

If a mobility aid, such as wheel chair, walker, or cane is used, it is important to collect information on the size of the mobility aid, as well as anthropometrical information about the client when using the mobility aid.

FORM 1: GETTING TO KNOW YOUR CLIENT (CONTINUED)

6. Personal Information about the Bathroom

Will more than one person be using the bathroom at the same time? How often?
What types of bathroom activities can be done in a shared bathroom space?
What types of activities need to be done in private?
How important is auditory privacy? Are bathroom noises a problem?

7. Visitability

Will this bathroom be used by visitors to the home? Overnight or just for social occasions?
Will the visitors be children or adults?
Do any regular or frequent visitors have any physical limitations?

FORM 1: GETTING TO KNOW YOUR CLIENT (CONTINUED)

8. Future Plans

How long do you plan to live in this home?
Do you anticipate changes in your household size or make-up?
Will this affect who uses the bathroom?
Is resale value of the home important?