Free Occupational Therapy Home Evaluation Template
Occupational Therapy Home Evaluation
[YOUR COMPANY NAME]
Date: [INSERT DATE]
Introduction
This evaluation aims to analyze the home environments of individuals with disabilities or injuries, identifying necessary modifications or accommodations.
Purpose
We will assess various facets of the home environment to pinpoint areas where independence and safety can be improved.
The evaluation criterion comprises the following:
Evaluation Criteria:
-
Accessibility: Ease of access to and within the residence.
-
Safety Measures: Implementation of appropriate, disability-specific safety measures.
-
Adaptive Equipment: Presence and proper usage of adaptive equipment.
-
Space Usage: Effective and safe utilization of space at home.
-
Personal Autonomy: Capacity for independent living within the current home set-up.
Instructions
Please evaluate the following aspects of your home environment based on the provided criteria. Rate each criterion on a scale from 1 to 5.
Rating Scale:
1 - Poor
2 - Below Average
3 - Average
4 - Above Average
5 - Excellent
Evaluation Form:
|
Criteria |
Details |
Rating (1-5) |
|---|---|---|
|
Accessibility |
Review of entry points, room layouts, and pathways in the home for ease of movement. |
|
|
Safety Measures |
Check for installation of safety measures, such as handrails, nonslip surfaces, adequate lighting, etc. |
|
|
Adaptive Equipment |
Assessment of accessibility and proper use of adaptive equipment, if present. |
|
|
Space Usage |
Study of storage solutions, furniture arrangement, and overall room configuration for optimal usage. |
|
|
Personal Autonomy |
Analysis of the resident's ability to independently perform daily tasks within the current environment. |
|
|
Environmental Hazards |
Identifying and reducing environmental risks like tripping, sharp edges, clutter, uneven surfaces, and electricity or chemical hazards. |
|
|
Comfort and Well-being |
Evaluating the comfort level of the home, considering temperature, ventilation, lighting, noise, and ambiance. |
|
|
Support Systems |
Assessing home support systems like emergency help, caregiver aid, community resources, and social links. |
Additional Comments and Notes:
|
Comments/Notes |
|---|
