Home Evaluation & Assessment for Independent Living & Accessibility

[LOGO]

HOME EVALUATION & ASSESSMENT FOR INDEPENDENT LIVING & ACCESSIBILITY

This form can be completed by direct observations that you gather and note, by asking your client and noting the responses, or by a little of both.

Today's Date, Time, Weather: ______

Client Name(s):______

Other Residents: ______

Address of Home:______

Telephone:______Budget Range (if known):______

Type/Style/Age of Home:______

HOA/Other Considerations:______

Brief Description of Home's Exterior, Grounds, Approach, Main Entry Perceived By You:

______

______

______

______

______

______

______

______

______

______

______

______

Brief Description of Home's Interior, Traffic Flow, Issues, Concerns:

______

______

______

______

______

______

______

______

______

______

______

______

Primary Needs, Tasks, Work, and Specific Rooms To Be Addressed Defined By Client:

______

______

______

______

______

______

______

______

Primary Needs, Tasks, Work, and Specific Rooms To Be Addressed Determined By HCP:

______

______

______

______

______

______

______

______

Primary Needs, Tasks, Work, and Specific Rooms To Be Addressed Perceived By You:

______

______

______

______

______

______

______

______

Use "L" (Light), "M" (Moderate, "S" (Severe) for Him, Her, and Other Occupants

General Conditions

HIM HEROTHER

______Vision

______Hearing

______Sense of feeling in arms and legs

______Sense of feeling in hands and feet

______Use of hands

______Arm strength

______Ability to stand

______Balance

______Use of neck

______Reaching, stretching, grasping

______Coordination

______Endurance, stamina

______Awareness, understanding

______Breathing

______Dressing, undressing

______Eating, cooking, meal preparation

______Using the bathroom

______Bathing, showering

______Getting up, sitting down

______Walking

General notes/observations:

Entry/Foyer

HIM HEROTHER

______Climbing up the outside stairs to the front door

______Going down the outside stairs from the front door

______Unlocking the front door

______Using the front door knob

______Holding the front door open, closing it

______Reaching and using the mailbox

______Walking over the lip at the threshold

______Ability to see in the area

General notes/observations:

Hallways & Inside Doors

HIM HEROTHER

______Opening and going through doors to enter another room

______Using interior door knobs

______Moving between carpeted and non-carpeted areas

______Seeing with available lighting

______Turning on lights when entering another room

General notes/observations:

Stairs (if present) – 2nd Floor or Basement (or both)

HIM HEROTHER

______Slipping on stairs

______Range-of-motion issues

______Distinguishing thresholds and edges

______Stamina in climbing stairs

______Physical ability to climb or descend stairs

______Balance

General notes/observations:

Kitchen

HIM HEROTHER

______Entering the room

______Turning lights on and off

______Using electrical outlets

______Opening and closing windows

______Seeing with available lighting

______Using cabinets, drawers, and countertop

______Using and reaching all parts of refrigerator, freezer

______Using oven, microwave

______Reaching fan switches

______Using stove, cooktop

______Ability to stand washing dishes in sink

______Ability to stand preparing food

______Ability to navigate kitchen safely

______Opening cans, jars, bottles

______Using faucet

______Cleaning countertop, table

______Cleaning, sweeping floor

______Dealing with glare on surfaces and floors

______Using dishwasher

______Using garbage disposal

______Importance of using the kitchen (1-10)

General notes/observations:

Living Room/Dining Room/Family Room

HIM HEROTHER

______Entering, leaving the room

______Turning lights on and off

______Using electrical outlets

______Opening and closing windows

______Seeing with available lighting

______Dealing with glare from natural or artificial light

______Opening and closing drapes, blinds, curtains

______Walking about within the room

______Moving between rooms

______Using the thermostat, turning on fans

______Issues with the flooring

______Watching, hearing TV

______Visiting with guests or family

General notes/observations:

Master Bedroom

HIM HEROTHER

______Entering, leaving the room

______Privacy, modesty

______Turning lights, ceiling fan on and off

______Using electrical outlets

______Opening and closing windows

______Seeing with available lighting

______Dealing with glare from natural or artificial light

______Opening and closing drapes, blinds, curtains

______Using closets, dressers

______Walking about within the room

______Using the thermostat

______Watching, hearing TV

______Issues with the flooring

______Noise level

General notes/observations:

Hall/Secondary Bathroom

HIM HEROTHER

______Entering, leaving the room

______Privacy, modesty

______Turning lights, fans on and off

______Using electrical outlets

______Using cabinets and closets

______Opening and closing windows (if present)

______Seeing with available lighting

______Dealing with glare from natural or artificial light

______Opening and closing drapes, blinds, curtains

______Walking about within the room

______Using mirror

______Using sink, faucet, and countertop

______Using toilet

______Using tub, shower

______Balance, coordination

General notes/observations:

Master Bathroom

HIM HEROTHER

______Entering, leaving the room

______Privacy, modesty

______Turning lights on and off

______Using electrical outlets

______Using cabinets and closets

______Opening and closing windows (if present)

______Seeing with available lighting

______Dealing with glare from natural or artificial light

______Opening and closing drapes, blinds, curtains

______Walking about within the room

______Turning on fan

______Using mirror

______Using sink, faucet, and countertop

______Using toilet

______Using tub, shower

______Balance, coordination

General notes/observations:

General notes/observations: