1 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. Client Name(s): Other Residents: Address of Home: Best Telephone: Budget Range (if known): Other contact information: 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 As Defined By Client: 2 Primary Needs, Tasks, Work, and Specific Rooms To Be Addressed As Determined By HCP: Primary Needs, Tasks, Work, and Specific Rooms To Be Addressed As Perceived By You:
General Conditions Use "L" (Light), "M" (Moderate, "S" (Severe) for Him, Her, and Other Occupants 3 Vision Hearing Sense of feeling in arms and legs Sense of feeling in hands and feet Use of hands Arm strength Range of motion shoulders, arms, hands Reaching, stretching, grasping Ability to stand Standing motion Squatting, bending, kneeling Getting up, sitting down Walking Climbing stairs (if any) Balance Use of neck Coordination Endurance, stamina Awareness, understanding Breathing Dressing, undressing Eating, cooking, meal preparation Using the bathroom Bathing, showering Brushing teeth, grooming
Entry/Foyer Climbing up the outside stairs to the front door (footing, mobility, strength) Going down the outside stairs from the front door (footing, mobility, strength) Unlocking the front door (vision, access, ease of use) Using the front door knob/handle 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 (lighting, vision) Room to wait comfortably for door to open/close 4 Hallways & Inside Doors Opening and going through doors to enter another room (width, type of opening, vision) Using interior door knobs/handles Moving between carpeted and non-carpeted areas Seeing with available lighting (vision, intensity, amount, color, natural v. artificial) Turning on lights when entering another room (access to switches, mobility) Maintaining balance
Stairs (if present) 2 nd Floor or Basement (or both) Slipping on stairs (flooring surface, balance) Range-of-motion issues Distinguishing thresholds, edges (noses), and risers no open risers Stamina in climbing stairs Physical ability to climb or descend stairs (mobility and strength) Balance while ascending or descending Ability to see well (lighting, vision, obstacles, shadows) 5 Kitchen Entering the room (opening, lighting, flooring transition, balance, vision) Turning lights on and off (type of switch, location, ability to reach and use) Using electrical outlets (height, location) Opening and closing windows (type of window, operating control) Seeing with available lighting (vision, amount, intensity, color, shadows) Opening cabinets or drawers (handles, reach, weight) Retrieving items from cabinets (upper, lower, larger wall pantries) or drawers Using countertop (height, depth, roll-under access) Using sink, faucet, and disposal to wash dishes, prepare food, clean-up (reach, depth, ease of use, lighting, height, stand or sit, access, flooring, vision, mobility, balance) Using and reaching all parts of refrigerator, freezer Using oven, microwave (opening door, controls, space to access) Using stove, cooktop (height, controls, residual heat) Placing hot or cooked items on a surface when removing from oven Reaching fan switches (access, mobility, vision, type of switch) Ability to stand preparing food (stamina, balance, mobility, space, flooring, lighting) Ability to navigate kitchen safely Opening cans, jars, bottles Cleaning countertop, table (balance, reach, hand and arm strength, range of motion) Cleaning, sweeping floor (balance, reach, hand and arm strength, range of motion) Dealing with glare on surfaces and floors
Using dishwasher (reach, access, range of motion) 6 Living Room/Dining Room/Breakfast Area Entering, leaving the room (access, footing, openings, lighting, vision, balance) Turning lights on and off (location, style) Using electrical outlets (height, location, behind furniture) Seeing with available lighting (vision, amount, intensity, color, natural or artificial) Opening and closing drapes, blinds, curtains Sitting and standing (availability of seating, height, type, access, mobility) Opening and closing drapes, blinds, curtains Walking about within the room (balance, non-slip, no obstacles) Moving between rooms (transitions, lighting, openness) Using the thermostat, turning on fans (location, vision, intuitive) Issues with the flooring (slippery, worn, color, glare, appearance, mobility) Watching, hearing TV (TV itself, location of it, sensory) Visiting with guests or family (seating, vision, hearing, lighting)
Family Room/Basement Entering, leaving the room (access, footing, openings, lighting, vision, balance) Turning lights on and off (location, style) Using electrical outlets (height, location, behind furniture) Seeing with available lighting (vision, amount, intensity, color, natural or artificial) Opening and closing drapes, blinds, curtains Walking about within the room (balance, non-slip, no obstacles) Moving between rooms (transitions, lighting, openness) Using the thermostat, turning on fans (location, vision, intuitive) Issues with the flooring (slippery, worn, color, glare, appearance, mobility) Watching, hearing TV (TV itself, location of it, sensory) Sitting and standing (availability of seating, height, type, access, mobility) Visiting with guests or family (seating, vision, hearing, lighting) 7 Master Bedroom Entering, leaving the room (access, doorway width, style of door, lighting) Privacy, modesty (door handles, locking mechanisms) Turning lights, ceiling fan on and off (access, mobility, location, style, reach, vision) Using electrical outlets (location, reach, behind furniture) Seeing with available lighting (vision, color, intensity, amount, types) Reading with available lighting (vision, color, intensity, amount, types) Opening and closing drapes, blinds, curtains (reach, strength) Using dressers and shelving (access, mobility, size and height, organization, lighting) Walking about within the room (flooring, stamina, balance, lighting, vision, safety) Using the thermostat or other wall controls (reach, vision, mobility) Watching, hearing TV (TV itself, location of it, sensory) Issues with the flooring (surface, resistance, type)
Noise level (ambient v. added, acceptable, quiet, loud, uncomfortable to hear well) Getting in and out of bed (access, mobility, height of bed, style of bed, balance) Using closets (access, lighting, doorway width and style, vision, mobility, organization) 8 Master Bathroom Entering, leaving the room (access, doorway width, style of door, lighting) Privacy, modesty (door handles, locking mechanisms) Turning lights, ceiling fan on and off (access, mobility, location, style, reach, vision) Using electrical outlets (location, reach, behind furniture) Using cabinets and closets (access, lighting, doorway style, vision, mobility, organization) Opening and closing windows (if present - type, controls, height, obstructions) Seeing with available lighting (shadows, intensity, brightness, color, vision) Opening and closing drapes, blinds, curtains (reach, strength) Walking about within the room (flooring, stamina, balance, lighting, vision, safety) Using mirror (height, size, lighting, vision) Using sink, faucet, and countertop (reach, depth, ease of use, lighting, height, stand or sit, access, flooring, vision, mobility, balance, stamina) Using toilet (standing, sitting, balance, access, ease of use, supports) Using tub, shower (size, access, ease of use, barriers, vision, lighting, handheld access, seating, footing, balance, coordination, stamina, function, supports, safety)
Secondary Bedrooms Entering, leaving the room (access, doorway width, style of door, lighting) Privacy, modesty (door handles, locking mechanisms) Turning lights, ceiling fan on and off (access, mobility, location, style, reach, vision) Using electrical outlets (location, reach, behind furniture) Seeing with available lighting (vision, color, intensity, amount, types) Opening and closing drapes, blinds, curtains (reach, strength) Using dressers and shelving (access, mobility, size and height, organization, lighting) Walking about within the room (flooring, stamina, balance, lighting, vision, safety) Using the thermostat or other wall controls (reach, vision, mobility) Watching, hearing TV (TV itself, location of it, sensory) Issues with the flooring (surface, resistance, type) Noise level (ambient v. added, acceptable, quiet, loud, uncomfortable to hear well) Getting in and out of bed (access, mobility, height of bed, style of bed, balance) Using closets (access, lighting, doorway width and style, vision, mobility, organization) 9 Hall/Secondary Bathroom Entering, leaving the room (access, doorway width, style of door, lighting) Privacy, modesty (door handles, locking mechanisms) Turning lights, ceiling fan on and off (access, mobility, location, style, reach, vision) Using electrical outlets (location, reach, behind furniture) Using cabinets and closets (access, lighting, doorway style, vision, mobility, organization) Opening and closing windows (if present - type, controls, height, obstructions) Seeing with available lighting (shadows, intensity, brightness, color, vision) Opening and closing drapes, blinds, curtains (reach, strength) Walking about within the room (flooring, stamina, balance, lighting, vision, safety)
Using mirror (height, size, lighting, vision) Using sink, faucet, and countertop (reach, depth, ease of use, lighting, height, stand or sit, access, flooring, vision, mobility, balance, stamina) Using toilet (standing, sitting, balance, access, ease of use, supports) Using tub, shower (size, access, ease of use, barriers, vision, lighting, handheld access, seating, footing, balance, coordination, stamina, function, supports, safety) 10 Laundry Room/Area Entering, leaving the room/area (access, doorway width, style of door, lighting) Turning lights on and off (location, style, access, vision) Using electrical outlets (height, location, access) Seeing with available lighting (vision, amount, intensity, color, natural or artificial) Opening and closing drapes, blinds, curtains Walking about within the room (balance, non-slip, no obstacles) Moving between rooms (transitions, lighting, openness) Using the thermostat, turning on fans (location, vision, intuitive) Issues with the flooring (slippery, worn, color, glare, appearance, mobility) Using closets, shelving, hanging rods (access, lighting, vision, reach, range of motion) Using sink, faucet, and folding areas (reach, depth, ease of use, lighting, height, stand or sit, access, flooring, vision, mobility, balance, stamina)
Home Office/Crafts Room Entering, leaving the room (access, doorway width, style of door, lighting) Turning lights on and off (location, style) Using electrical outlets (height, location, behind furniture) Seeing with available lighting (vision, amount, intensity, color, natural or artificial) Opening and closing drapes, blinds, curtains (reach, strength) Walking about within the room (balance, non-slip, no obstacles) Moving between rooms (transitions, lighting, openness) Using the thermostat, turning on fans (location, vision, intuitive) Issues with the flooring (slippery, worn, color, glare, appearance, mobility) Watching, hearing TV (TV itself, location of it, sensory) Visiting with guests or family (seating, vision, hearing, lighting) Sitting and standing (availability of seating, height, type, access, mobility) Using closets, shelving, storage (access, lighting, vision, reach, range of motion) 11 Patio/Deck/Sitting Porch/Outdoor Area Entering, leaving the area from the home (access, doorway width, style of door, lighting) Turning lights on and off (location, style) Using electrical outlets (height, location, behind furniture) Seeing with available lighting (vision, amount, intensity, color, natural or artificial) Opening and closing drapes, blinds, curtains Walking about within the space (balance, non-slip, no obstacles) Moving to and between space to home (transitions, lighting, openness) Turning on fans and lights (location, vision, intuitive) Issues with the flooring (slippery, worn, color, glare, appearance, mobility) Watching, hearing TV (TV itself, location of it, sensory) Visiting with guests or family (seating, vision, hearing, lighting)
12 Garage/Other Areas Entering, leaving the area from the home (access, doorway width, style and swing of door, step-down, stairs, landing area, lighting) Turning lights on and off (location, style) Using electrical outlets (height, location, obstacles) Seeing with available lighting (vision, amount, intensity, color, natural or artificial) Opening and closing drapes, blinds, curtains (reach, strength) Walking about within the room (balance, non-slip, no obstacles) Turning on fans (location, vision, intuitive) Issues with the flooring (slippery, worn, color, glare, appearance, mobility) Sitting and standing (availability of seating, height, type, access, mobility) Using closets, cabinets, shelving, storage, bins (access, lighting, vision, depth, height, reach, range of motion)