Home Assessment

How to complete the questionnaire: Using a tape measure and pen, start the tour of your home. Follow the sequence of pages, measuring door widths, stair tread depths and heights, inspecting floor surfaces, etc. Answers can be recorded on the form either by circling yes, no, n/a (not applicable), or by written comment. If a question does not apply to your home, please continue to the next question. Comments can be included on any or all of the questions.

Is there a continuous hard and evenly smooth surface to the door?	YES NO N/A
Are there any steps that approach the door?	YES NO N/A
Is there a handrail or a grab bar along the steps or the ramp for stability?	YES NO N/A
Is the pathway to the door free of obstacles (ivy, ground cover)?	YES NO N/A
Is there enough room to assist someone with a walker?	YES NO N/A
Is the pathway well lit during the evening hours?	YES NO N/A
If there is a wood deck, are the deck planks even and not warped?	YES NO N/A
Is a person in a wheelchair easily able to maneuver up the ramp?	YES NO N/A
Is there enough room for someone assisting another to easily get in the door?	YES NO N/A
Is the peephole on the entry door at a usable height?	YES NO N/A
Is there a sidelight or window at the entry door?	YES NO N/A
Is there a chair or small table near the entry to set articles on?	YES NO N/A
Is there a doorbell at the entry door?	YES NO N/A
How high is the threshold strip from the outside of the exterior door?	Height of threshold _______________________
What type of door handles are used (round, lever, etc.)?	_______________________ _______________________
How many steps approach the door?	# of steps into house _______________________
How high are the risers on the steps?	Height of riser _______________________

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Is there a need for open space under the sink or vanity?	YES NO N/A
Are the faucet controls easy to use?	YES NO N/A
Is the mirror at a good height?	YES NO N/A
Is the toilet at a good height?	YES NO N/A
Is the tub easy to get in and out of?	YES NO N/A
Is there a tub or shower seat in the bathing area?	YES NO N/A
Is there a non-slip surface in the tub or shower?	YES NO N/A
Do you need grab bars by the toilet?	YES NO N/A
Do you need grab bars at the tub or shower?	YES NO N/A
If you have grab bars, are they sturdy?	YES NO N/A
Is the toilet paper dispenser within your reach?	YES NO N/A
Are the towel racks at a good height for you?	YES NO N/A
Is there adequate storage within your reach?	YES NO N/A
Are the medicine cabinets within your reach?	YES NO N/A
Is the medicine cabinet easy to open?	YES NO N/A
Is there enough space to move around in the bathroom?	YES NO N/A

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Is there plenty of circulation space around the bed and dressers?	YES NO N/A
Is the bed at a good height?	YES NO N/A
Are items in the closet easily reached?	YES NO N/A
Are there shoe racks or shelves to get shoes up off the floor?	YES NO N/A
Where is the master bedroom located (main floor or another level)?	_______________________ _______________________

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Is the dryer at a height that is easily used?	YES NO N/A
Can you easily reach into the washer?	YES NO N/A
Are the laundry detergents and softeners easily reached?	YES NO N/A
Is there a worktable for setting laundry baskets and clean clothes?	YES NO N/A
Do you use an ironing board?	YES NO N/A
Is the ironing board manual or built in?	_______________________ _______________________
What type of lighting is used in the room (task, single light)?	_______________________ _______________________
Where are the laundry facilities located (first floor, second, basement)?	_______________________ _______________________

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Is there plenty of clear circulation space?	YES NO N/A
How are the seat heights of the sofas and chairs (are they comfortable)?	YES NO N/A
Is the furniture firm enough?	YES NO N/A
Are the chairs or sofas arranged near windows to provide better daylight?	YES NO N/A
Is there any type of level change in the living room (sunken or raised)?	YES NO N/A
Are any of these lights operable by remote, clapper, or touch?	YES NO N/A
Are the light switches easy to reach?	YES NO N/A
Are the electrical outlets easy to reach?	YES NO N/A
Are there area or throw rugs inside the home?	YES NO N/A
Are the rugs secured in place?	YES NO N/A
Can windows be easily opened?	YES NO N/A
Is the window latch at a height that is easy to operate?	YES NO N/A
Are the windows a double hung or casement style?	_______________________ _______________________
How many lights are there?	# of lights _______________________

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Is there plenty of room to maneuver around the table in a walker or wheelchair?	YES NO N/A
Are the chair's seat height comfortable?	YES NO N/A
Are the chairs sturdy?	YES NO N/A
Is the table at a good height for getting up from the table?	YES NO N/A
Are there any obstacles in the paths between rooms?	YES NO N/A
Is there a hanging light over the table?	YES NO N/A
If there is a hanging light, is it at a good height?	YES NO N/A
Are the counter heights at good working heights?	YES NO N/A
Is there adequate counter space next to the refrigerator, stove and sink?	YES NO N/A
Are the cabinets at a height that the shelves are easily reached?	YES NO N/A
Do any of the shelves of the lower cabinets pull out like a drawer?	YES NO N/A
Can you easily reach the back of the lowest cabinet shelf?	YES NO N/A
Could small items be arranged on tiers to keep them closer to the front?	YES NO N/A
Are electrical outlets easily reached from the counter space?	YES NO N/A
While working at the counter, sink or stove, would it be easier if you were seated?	YES NO N/A
Is there an open space below the cabinets to allow for seating?	YES NO N/A
While working at the sink, can you easily reach the back of the sink?	YES NO N/A
Are the faucets easy to operate?	YES NO N/A
Is there a garbage disposal? If yes, is the control switch reachable?	YES NO N/A
While working at the stove, can you easily see into the pots on the back burners?	YES NO N/A
Are the controls for the stove easy to operate (grasp and turn)?	YES NO N/A
Are the controls clearly marked for off and on positions?	YES NO N/A
Is it difficult to reach in and out of the oven?	YES NO N/A
Is the oven or stove installed at a comfortable height?	YES NO N/A
Are the lower bins in the refrigerator too low?	YES NO N/A
Are you able to reach to back of the refrigerator?	YES NO N/A
If there is a food pantry, can items be easily reached?	YES NO N/A
Is there a smoke detector?	YES NO N/A
How is the room lit?	_______________________ _______________________
What type of lighting is used in the kitchen?	_______________________ _______________________
Can you reach the upper shelves or cabinets?	_______________________ _______________________
Is the freezer a side by side or upper and lower freezer unit?	Side by Side ________ Upper/Lower ________

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Are there handrails on both sides of the stairway?	YES NO N/A
How wide are the doorways for each room?	Doorway width _______________________
How high are the thresholds to the interior rooms?	Height of threshold _______________________
How is the stairway lit (one single light, or multiple lights)?	_______________________ _______________________
How is the hallway lit (one single light, or multiple lights)?	_______________________ _______________________

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Is there room on both sides of the car to easily get in and out of the car?	YES NO N/A
Is there enough room to load a wheelchair or maneuver a walker?	YES NO N/A
Are there items stored in the pathway to the door of the house?	YES NO N/A
Is there motor oil or other substances on the floor that may cause one to slip?	YES NO N/A
Is there good lighting in the garage for entering and exiting?	YES NO N/A
Is there a handrail or a grab bar along the steps or the ramp for stability?	YES NO N/A
Are there steps into the house?	YES NO N/A
How many steps are there into the house?	# of steps into house _______________________
How high are the risers on the steps?	Height of riser _______________________