Survey — Re:model

HOME EVALUATION & ASSESSMENT FOR INDEPENDENT LIVING & ACCESSIBILITY

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

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 Parent/s:

_______________________________________________________________________________

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

_______________________________________________________________________________

General Conditions

HIM HER OTHER

_____ _____ _____ 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

_____ _____ _____ Other: __________________________________________

Entry/Foyer

HIM HER OTHER

_____ _____ _____ 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 postbox

_____ _____ _____ Walking over the lip at the threshold

_____ _____ _____ Ability to see in the area (lighting, vision)

_____ _____ _____ Room to wait comfortably for door to open/close

_____ _____ _____ Other: __________________________________________

Hallways & Inside Doors

HIM HER OTHER

_____ _____ _____ 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, colour, natural v. artificial)

_____ _____ _____ Turning on lights when entering another room (access to switches, mobility)

_____ _____ _____ Maintaining balance

_____ _____ _____ Other: __________________________________________

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

HIM HER OTHER

_____ _____ _____ 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)

_____ _____ _____ Other: __________________________________________

Kitchen

HIM HER OTHER

_____ _____ _____ 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, colour, 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, taps, 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 hob, 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)

_____ _____ _____ Other: __________________________________________

Living Room/Dining Room/Breakfast Area

HIM HER OTHER

_____ _____ _____ Entering, leaving the room (access, footing, openings, lighting, vision, balance)

_____ _____ _____ Turning lights on and off (location, style)

_____ _____ _____ Using electrical outlets (height, location, behind furniture)

_____ _____ _____ Opening and closing windows (type, controls, objects in front of them)

_____ _____ _____ Seeing with available lighting (vision, amount, intensity, colour, natural or artificial)

_____ _____ _____ Dealing with glare from natural or artificial light

_____ _____ _____ 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, colour, glare, appearance, mobility)

_____ _____ _____ Watching, hearing TV (TV itself, location of it, sensory)

_____ _____ _____ Visiting with guests or family (seating, vision, hearing, lighting)

_____ _____ _____ Other: __________________________________________

Family Room