Home Evaluation Questionnaire for PLOF Patient name: A primary goal of rehabilitation is to return the patient to his or her former environment and lifestyle. An evaluation of physical structure of the patient's home is an essential component of overall rehabilitation planning. The purpose of this questionnaire is to assist us with the patient s prior level of function/prior living arrangement, to assist the patient and family in preparing the home for the return of the family member, and to assist the therapists in making recommendations to ensure the safety of both the patient and the family. Please contact the Rehabilitation Department with any questions concerning this questionnaire.
Prior Level of Function/ Prior Living Arrangement: -Did the patient live alone? -Did the patient live with family or friends? If so, who? -How often were they home? -Did the patient need assistance with the following: -Dressing? -Bathing? -Eating? -Getting into/out of bed? -Getting onto or off toilet? -Getting into tub or shower? -Ambulation? Device used (i.e. walker, cane)? If so, what? -Check writing and balancing of checkbook? -Paying bills? -Medication management? Pill box? - Household chores (laundry, trash, cleaning etc)? -What hobbies did the patient enjoy prior to this illness? -Will the patient be responsible for childcare? If yes, give number and ages of children -Will the patient be responsible for other family members? If yes, who and how much assistance do they require? -Will the patient do own shopping? -Is family member or friend available? -Is delivery service available? -Will the patient be required to prepare their own meals? -Will meals be prepared and the patient needs only to warm up food? -Will special accommodations be made for meals, such as meals on wheels? -Will the patient be responsible to get mail from mailbox? -Does family have an automobile? -Will the patient be driving? -Will the patient be scheduling their own appointments? -Is family member or friend available to help with yard care, change a high light bulb, etc.?
HOME EVALUATION GENERAL CONSIDERATIONS ENTRANCE TO HOME 1. Should allow easy entry---preferably independent entry---by patient. 2. The condition of the stairs should be noted. 3. The condition and length of the pavement surface leading to the entryway should be noted. 4. If a ramp is necessary, there should be one foot of ramp per one inch of rise. FURNITURE ARRANGEMENT 1. Should allow sufficient room for maneuvering wheelchair or assistive device. 2. Should provide clear passage from one room to the next. 3. Should allow access to electrical outlets, telephone, and wall switches. 4. Is there any sharp edged furniture that should be relocated? BATHROOM 1. Nonskid adhesive strips should be placed on the floor of the bathtub and/or shower. FLOORS 1. All floor coverings should be glued or tacked to the floor. 2. Throw (scatter) rugs should be removed. 3. Nonskid waxes should be used. DOORS Doorways need to be inches wide to allow clearance for wheelchair or assistive device. HEATING UNITS All radiators, heating vents, and hot water pipes should be appropriately screened off to prevent burns. THERMOSTATS Is it accessible and located for easy adjustment? FIRE EXTINGUISHER It should be available for easy access. CLUTTERED AREAS Review and rearrange any areas that act as barriers to walking aides or wheelchairs.
HOME EVALUATION QUESTIONNAIRE APARTMENT: ONE FLOOR HOME: TWO OR MORE FLOORS: What floor does the patient live on? Is an elevator available? Yes No Location of bedroom? Location of bathroom? BASEMENT: Does patient use basement area? Yes No Home located on hill or level surface? Does the patient require access to the garage? Yes No Is the driveway/garage/sidewalk accessible? Will it be necessary for the patient to go up or down stairs inside the home? Width of stairway Number of steps Is railing present going up? (Note left/right or both) Is landing present? ENTRANCES TO BUILDING OR HOME (Mark all available entrances) FRONT BACK SIDE Which entrance is used most frequently? Number of steps? Is railing present as you go up? Note handrail location: right, left, or both sides Is ramp available? Is space available for a ramp? Does door swing in? Does door swing out? Width of doorway? (door frame to door frame)
LIVING/ FAMILY ROOM AREA LIGHTING (circle): Wall switch, lamp(s), other FLOORING (circle): Tile; linoleum; hardwood; carpet: plush, shag, area rug, indoor/outdoor carpet, throw rug(s) FURNITURE: Is placement such that a wheelchair or other assistive device could be used in the room? Height of favorite chair/sofa seats? Could furniture be rearranged? Height of sofa seat? Height of chair seats? Do chairs have arms? Do chairs swivel? Are television and radio within easy reach? DINING ROOM LIGHTING (circle): Wall switch, lamp(s), other FLOORING (circle): Tile, linoleum; hardwood; carpet: plush, shag, area rug, indoor/outdoor carpet, throw rug(s) FURNITURE: Is placement such that a wheelchair or other assistive device could be used in the room? Could furniture be rearranged? Table (height from floor to bottom)? Height of chair seats? Do chairs have arms? TELEPHONES Locations (type: rotary, push-button, cordless, other ) (type: rotary, push-button, cordless, other ) (type: rotary, push-button, cordless, other ) Does patient have neighbor, police and fire department, and physician numbers posted near telephone? Can numbers be programmed into telephone? BEDROOM LIGHTING (circle): Wall switch, bedside lamp, night light, other FLOORING (circle): Tile, linoleum; hardwood; carpet: plush, shag, area rug, indoor/outdoor carpet, throw rug(s) BED: Height Width Headboard present Footboard present Are both sides accessible? Is bed on wheels? Is it stable? Is night table within reach from bed? Is telephone on it? Where is patient's clothing located?
BATHROOM LIGHTING (circle): Wall switch, mirror light, night light, other FLOORING (circle): Tile, linoleum; hardwood; carpet: plush, shag, area rug, indoor/outdoor carpet, throw rug(s) WALLS surrounding bathtub and toilet (circle): Tile, plaster, other TOILET: Is there clearance for wheelchair to be positioned near toilet? What is the height of the toilet seat from the floor? Location of toilet paper? Are there sturdy bars near the toilet? Is there room for grab bars? SINK: What is the height of the sink? Is there knee space beneath the sink? Type of faucet controls (circle): knob, handle, other BATHTUB/SHOWER (circle): Walk-in shower; bathtub with shower; bathtub on legs; no shower Is a personal shower head available? Are there sliding glass doors? curtain? hinged door? Shower doorway width? Width of bathtub from inside? Please include a small diagram or photograph of the location of doorway, toilet, bathtub, and shower.
KITCHEN LIGHTING (circle): Wall switch, lamp(s), other FLOORING (circle): Tile, linoleum; hardwood; carpet: plush, shag, area rug, indoor/outdoor carpet, throw rug(s) TABLE: (height from floor to bottom) KITCHEN CHAIRS WITH ARMS: REFRIGERATOR (circle type): Side-by-side freezer/fridge; top/bottom freezer/fridge COUNTER: (height from floor to counter top) OVERHEAD CABINETS: (height of doors from counter top) ; are frequently used items visible and easily reached (front of patry and refrigerator)? SINK: Type of faucet controls (circle): knob, handle, other STOVE/OVEN (circle type): Electric, gas range, toaster oven, microwave, wall unit, other Controls: (location): front, rear (type): knobs, push-buttons OUTLETS: Location and distance from floor Please include a small diagram or photograph of kitchen (include stove, counters, sink, tables, refrigerator, etc.) HALLWAYS Can wheelchair or walking aide be maneuvered in hallway? Hallway width? Door width? Door swing in or swing out
LAUNDRY How will laundry be managed? Location of facilities in home Are laundry supplies easy and safe to reach? DOOR: Width Swing in Swing out WASHER: Top-load Front-load Accessible DRYER: Top-load Front-load Accessible OTHER Are there fire extinguishers and smoke detectors in the house? Are there any pets in the house that might be obstacles for the patient? Is hearing adequate for: doorbell? telephone? smoke alarm? alarm clock? tornado sirens? radio/television? Are cognitive skills adequate for operation of: appliances? temp controls? door/window locks? other? RAMPING GUIDELINES
1. For every inch of rise, there should be 1 foot of ramp. The rise is determined by measuring the height of the steps, including the door threshold (i.e., when total rise is 24 inches, ramp length should be 24 feet). 2. Pressure-treated lumber, marine plywood, or concrete should be used for exterior ramp construction. The ramp/platform should have a nonslip surface (e.g., gritty paper adhesive, nonskid paint, or, if surface is concrete, a broom finish). Ramp footings should be excavated to below the frost line. 3. Door thresholds should have a maximum height of one-half inch. 4. A platform (5 feet by 5 feet) that is level with the door threshold should be constructed immediately outside the doorway with an 18-inch space (minimum) opposite the door swing for wheelchair approach. 5. Ramp surfaces are recommended to be 42 inches wide (minimum) and to extend from level platforms. 6. Bilateral railings should be present and at a maximum height of 32 inches. The ideal width of the railing grip is 1.5 inches. Railings should extend 1 inch beyond the end of the ramp. Ends of railings should be turned down to avoid dangerous projections. 7. A four-inch-high curbing should border the perimeter of the ramp and platform surfaces to prevent wheelchairs from deviating from the path of the ramp. 8. At the ramp bottom, six feet of straight clearance is recommended. 9. Level platforms (5 feet by 5 feet) are required for safety and resting in ramps longer than 30 feet and wherever the ramp surface turns. 10. Overhead coverings for ramped surfaces are suggested. Anderson, Betsy W. and Ross, Julianne M. Smoothing the transition home, Clinical Management, Vol. 12 No. 5 (September/October 1992)