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Home Assessment

This questionnaire asks the homeowner or caregiver to evaluate the rooms throughout the home. Through a series of questions, the homeowner can determine if only a room or perhaps the entire home is a candidate for home modification. The questions are designed to identify the simple things that can become obstacles as physical independence begins to diminish.

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.
bedroom bath kitchen garage living hallway wash/dry entry


The Entry

Is there a continuous hard and evenly smooth surface to the door?
YESNON/A
Are there any steps that approach the door?
YESNON/A
Is there a handrail or a grab bar along the steps or the ramp for stability?
YESNON/A
Is the pathway to the door free of obstacles (ivy, ground cover)?
YESNON/A
Is there enough room to assist someone with a walker?
YESNON/A
Is the pathway well lit during the evening hours?
YESNON/A
If there is a wood deck, are the deck planks even and not warped?
YESNON/A
Is a person in a wheelchair easily able to maneuver up the ramp?
YESNON/A
Is there enough room for someone assisting another to easily get in the door?
YESNON/A
Is the peephole on the entry door at a usable height?
YESNON/A
Is there a sidelight or window at the entry door?
YESNON/A
Is there a chair or small table near the entry to set articles on?
YESNON/A
Is there a doorbell at the entry door?
YESNON/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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The Bathroom

Is there a need for open space under the sink or vanity?
YESNON/A
Are the faucet controls easy to use?
YESNON/A
Is the mirror at a good height?
YESNON/A
Is the toilet at a good height?
YESNON/A
Is the tub easy to get in and out of?
YESNON/A
Is there a tub or shower seat in the bathing area?
YESNON/A
Is there a non-slip surface in the tub or shower?
YESNON/A
Do you need grab bars by the toilet?
YESNON/A
Do you need grab bars at the tub or shower?
YESNON/A
If you have grab bars, are they sturdy?
YESNON/A
Is the toilet paper dispenser within your reach?
YESNON/A
Are the towel racks at a good height for you?
YESNON/A
Is there adequate storage within your reach?
YESNON/A
Are the medicine cabinets within your reach?
YESNON/A
Is the medicine cabinet easy to open?
YESNON/A
Is there enough space to move around in the bathroom?
YESNON/A

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The Bedroom

Is there plenty of circulation space around the bed and dressers?
YESNON/A
Is the bed at a good height?
YESNON/A
Are items in the closet easily reached?
YESNON/A
Are there shoe racks or shelves to get shoes up off the floor?
YESNON/A
Where is the master bedroom located (main floor or another level)? _______________________
_______________________

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The Laundry

Is the dryer at a height that is easily used?
YESNON/A
Can you easily reach into the washer?
YESNON/A
Are the laundry detergents and softeners easily reached?
YESNON/A
Is there a worktable for setting laundry baskets and clean clothes?
YESNON/A
Do you use an ironing board?
YESNON/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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The Living Room

Is there plenty of clear circulation space?
YESNON/A
How are the seat heights of the sofas and chairs (are they comfortable)?
YESNON/A
Is the furniture firm enough?
YESNON/A
Are the chairs or sofas arranged near windows to provide better daylight?
YESNON/A
Is there any type of level change in the living room (sunken or raised)?
YESNON/A
Are any of these lights operable by remote, clapper, or touch?
YESNON/A
Are the light switches easy to reach?
YESNON/A
Are the electrical outlets easy to reach?
YESNON/A
Are there area or throw rugs inside the home?
YESNON/A
Are the rugs secured in place?
YESNON/A
Can windows be easily opened?
YESNON/A
Is the window latch at a height that is easy to operate?
YESNON/A
Are the windows a double hung or casement style? _______________________
_______________________
How many lights are there? # of lights
_______________________

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The Kitchen

Is there plenty of room to maneuver around the table in a walker or wheelchair?
YESNON/A
Are the chair's seat height comfortable?
YESNON/A
Are the chairs sturdy?
YESNON/A
Is the table at a good height for getting up from the table?
YESNON/A
Are there any obstacles in the paths between rooms?
YESNON/A
Is there a hanging light over the table?
YESNON/A
If there is a hanging light, is it at a good height?
YESNON/A
Are the counter heights at good working heights?
YESNON/A
Is there adequate counter space next to the refrigerator, stove and sink?
YESNON/A
Are the cabinets at a height that the shelves are easily reached?
YESNON/A
Do any of the shelves of the lower cabinets pull out like a drawer?
YESNON/A
Can you easily reach the back of the lowest cabinet shelf?
YESNON/A
Could small items be arranged on tiers to keep them closer to the front?
YESNON/A
Are electrical outlets easily reached from the counter space?
YESNON/A
While working at the counter, sink or stove, would it be easier if you were seated?
YESNON/A
Is there an open space below the cabinets to allow for seating?
YESNON/A
While working at the sink, can you easily reach the back of the sink?
YESNON/A
Are the faucets easy to operate?
YESNON/A
Is there a garbage disposal? If yes, is the control switch reachable?
YESNON/A
While working at the stove, can you easily see into the pots on the back burners?
YESNON/A
Are the controls for the stove easy to operate (grasp and turn)?
YESNON/A
Are the controls clearly marked for off and on positions?
YESNON/A
Is it difficult to reach in and out of the oven?
YESNON/A
Is the oven or stove installed at a comfortable height?
YESNON/A
Are the lower bins in the refrigerator too low?
YESNON/A
Are you able to reach to back of the refrigerator?
YESNON/A
If there is a food pantry, can items be easily reached?
YESNON/A
Is there a smoke detector?
YESNON/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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The Hallway

Are there handrails on both sides of the stairway?
YESNON/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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The Garage

Is there room on both sides of the car to easily get in and out of the car?
YESNON/A
Is there enough room to load a wheelchair or maneuver a walker?
YESNON/A
Are there items stored in the pathway to the door of the house?
YESNON/A
Is there motor oil or other substances on the floor that may cause one to slip?
YESNON/A
Is there good lighting in the garage for entering and exiting?
YESNON/A
Is there a handrail or a grab bar along the steps or the ramp for stability?
YESNON/A
Are there steps into the house?
YESNON/A
How many steps are there into the house? # of steps into house
_______________________
How high are the risers on the steps? Height of riser
_______________________