Occupation-based Home Assessment

Client Name:___Ms. M________

Assessment:___9/1/14_________
Type of Housing: house__X_
home______ Other______

Date of
apartment______

mobile/motor

Residents in home:_Ms. M and her pets (2 dogs/1 cat)___________

Area outside and immediately surrounding the home:
What occupations, if any, take place in the area immediately surrounding the home
and/or inside the garage? Construction of art activities for leisure and hobby.

Terrain:

Incline

Grass

Pavement Other

Porch/Patio/Balcony/N.A.
Surface material: smooth concrete
Number of stairs: two stairs
Height of stairs: 5 inches each
Railing present (location, height, ease of use): No railing present
Type and width of door to area: 3 ft
Type of furniture/ease of use: couch,
Plugs/switches (location, height, ease of use): Right by doors, apprx 5 ft
height
Yard
Maintenance required: Yes
How maintenance is completed currently: Mow lawn with manual mower,
water, and maintain 3 trees and rose bushes in backyard.
Equipment/activities present (play, hobby, work, machinery): sewing
machines for art and crafts and gardening tools for grass and trees.
Ease/efficiency of use of equipment: easy to store and locate in shed.
Garage/workshop

How many cars: one car.

Proximity of cars to entrance: 10-15 ft from car to front door.
Number and height of steps from garage to entrance: approx 5 in in height.
Railing present (location, height, ease of use): No railing present.
Storage systems: No storage systems.
Ease/efficiency of use of tools/equipment: tools readily available on tables
and drawers, tools reinforced on walls.
Ways to improve occupational performance, improve mobility, and/or improve
safety in area immediately surrounding the home? Repair driveway, trip concern
due to cracks and gaps on pavement.
Front Entrance
Number and height of steps: 2 steps, approx. 5 in height.
Railing present (location, height, ease of use): No railing.
Surfaces: concrete.
Types of knobs/locks: standard hard plastic or other materials.
Width of door: 5 ft
Back Entrance
Number and height of steps: No steps in back yard.
Railing present (location, height, ease of use): No railing.
Surfaces: concrete for patio and grass in backyard.
Types of knobs/locks: sliding glass door.
Width of door: glass door opens up to 7 ft.
Any concerns with safety/ease/convenience of entering the home? Not with
backyard. Easily to access with sliding door.

Kitchen
List all occupations that take place in the kitchen and the primary users of this
space: Cooking meals 2-3 times a day.
Width of doorway into kitchen: 6 ft from entering to kitchen
Height of kitchen dining table: 3 ft.
Height of countertops: 4 ft.
Continuous surfaces for sliding objects? All countertops are smooth surfaces.
Type of stove: Gas stove.
Types and location of controls on stove/burners: Turn knobs to start gas
controls.
Types of controls on oven: Turn switches/knobs.
Height of oven: 2 ft.
Effort needed to open/close oven: easy to open and close.
Are pots/pans too heavy or do they get too hot? No, pots and pans are not
heavy. Client uses necessary gloves to remove hot pots/pans.
Type of refrigerator: refrigerator on top and freezer is on bottom.
Height of handles and refrigerator shelves: refrigerator handles are vertical
and close to one another, pull to open doors. Freezer handle is horizontal and
pull to open the shelf like drawer.
Depth of shelves: 3 ft depth of fridge. Freezer is larger approx. 4 ft.
Dishwasher controls: push buttons and knobs to turn.
Ease of loading/unloading: Dishwasher is front loaded, easy for client.
Ease of transporting items: Easy for client.
Plugs/switches: height, ease of use: plugs are at lower levels located on walls,
client must bend down to access them. Switches are at chest level for the
client so they are easily accessible.
Storage (ability to reach, handles, organization, amount): Storage of items
are easily accessible and well stored on walls with secure placement.

DME typically used in this area: Client does not require any DME at this time.
Ways to improve occupational performance, improve mobility, and/or improve
safety in kitchen area? Remove clutter on kitchen table and counter tops when
preparing for food.

Bathroom
Occupations that take place in the master bath: Self-care activities: bathing,
grooming, and brushing teeth, applying makeup.
Width of doorway: 3 ft.
Flooring: hard wood, smooth surface.
Types of faucets at sink: Kohler faucet; handle requires to lift to turn on water.
Types of faucets in tub/shower: Easy grab lever to move handle to
appropriate temperature.
Non-skid surface in tub/shower: No non-skid surface in shower.
Height of step into tub/shower: Small step, 5 inches.
Height of toilet: 3 ft
Type of lever to flush: Horizontal push lever to flush.
Location of toilet paper: Located to the left of client when sitting, within easy
reach at elbow level when arm is extended.
Plugs/switches: Switches can be easily flipped on/off with vertical switches.
Height of mirror: 4 ft.
Cupboards (height, type of handle, organization): Located underneath
bathroom sink and knobs are attached. Client must pull to access cupboards.
DME typically used in this area: No DME is currently used by client.
Ways to improve occupational performance, improve mobility, and/or improve
safety in bath area? Client just remodeled bathroom in order to be easily functional
for her occupational needs.
Bedroom
Occupations that take place in the bedroom area: Sleep, rest.

Doorway width: 3.5 ft.

Type of door/knob to access closet: Sliding door to access closet. Small knob
to grasp while sliding door.
Height of closet rod: 4.5 ft.
Type of handles, ease of use of Dresser drawers: Drawers are easily
accessible; handles are rounded so easy to grasp and pull to open, push to
close.
Organization of storage/ease of finding items? Closet is large, storage of
clothes and other materials are easily accessible and easy to find.
Height and type of Lighting: Lamp in room and overhead fan with ceiling
light. Lamp is 4.5 ft.
Ease of access to lighting by the bed: The lamp is accessible by light switch
on wall next to doorway.
DME typically used in this area: No DME is used by the client at this time.
Ways to improve occupational performance improve mobility and/or improve safety
in bedroom area? Remove clutter on floor and organize storage space for clothing
material.
Living room
Occupations that take place in the living room: Leisure activities such as watching
TV, reading and relaxing, listening to music, and read art magazines.
Doorway width: N/A. The living room opening is connected to kitchen and
hallway that is quite wide.
Most used furniture (type and height): Couch which is shaped like an L. 4ft
height.
Locations and Ease of access to electronics: Electronics are easily accessible
near couch by remote access.
Types and controls of window coverings: Windows open manually by
unlocking latches and pushing upwards.
Types of controls to open/close windows: Latches to unlock/lock, manually
push and pull to open and close.
Storage (type, access, organization): Bookshelves for books and magazines.
DME typically used in this area: DME not currently used by client for this area.

Ways to improve occupational performance, improve mobility, and/or improve ease

of use in living room area? Mobility for living room area is good at this time. No
clutter on floor that she could potentially trip on or cords from electronics.

Cleaning:
Laundry (front/side load, controls, storage of detergent): Washer is top loaded
with flipping of lid to load and unload clothes. Dryer is front loaded and door must
be open and closed with a pull toward client.
Supplies (able to reach, organization, location): Detergent is located on top of
dryer so easy to access along with dryer sheets.
Garbage removal (bags, process, transport): Bags are taken to larger garbage
bin which are located at the side of the house. Garbage bags are located in kitchen
area underneath the sink.
Equipment (vacuum, mop, broom, dustpan): Vacuum is located in storage
closet in hallway that leads to living room.
Ways to improve occupational performance, improve mobility, and/or improve ease
of use related to cleaning? Items are all located in storage and easily accessible.
Laundry detergent and dryer sheets could be placed on small shelf next to washer
and dryer machines.
Other considerations
Ease of access to communication within and throughout the home: Client has cell
phone and landline located in her home. Each is easily accessible in the home.
Access and ease of use of Thermostat: Located in central hallway near bedrooms at
clients neck level (approx. 4.5 ft).
Access to Community Transportation: Client does not use community transportation
but there is a city bus that travels 3 blocks away from her neighborhood.
Access to grocery Store, drug store, etc.: Client drives to grocery store approx. 3
miles away from her home.
Pets in the home and any related safety concerns: Client has 2 dogs and one cat.
Client is able to ambulate functionally with pets in the home.

Presence of environmental hazards (rugs, cords, obstacles in major pathways, etc.):

Obstacles on floors of bedrooms and garage that could be a trip hazard.
Recommend client pick up objects and organize.

Summary: List the top 5 modifications to the space that you feel would have the
biggest impact on improving occupational performance, mobility, and/or safety in
the home.
1. Front yard and entrance to house: fix cracks in pavement that may be trip hazard
in future.

2. Garage area: Remove clutter on surrounding floor; clean laundry area.

3. Spare bedroom: Needs to be cleaned and removal of clutter, boxes.

4. Chair in garage: Improper fitting of clients chair. Needs to be fitted properly for
clients posture.

5. Kitchen area: Clutter on table needs to be removed, clutter on floor surrounding

table.

Additional recommendations: Client is I w/ all ADLs and IADLs at this time. No DME
required for use.

Occupational Therapist Name Printed: ________________________________________

Signature: _______________________________________________________________
Date and time:____________________________________________________________