Free Home Assessment Form Template
Home Assessment Form
Please take a few moments to complete this assessment.
Patient Information
Name
Date of Birth
Phone number
Address
Type of Mobility Assistive Equipment (MAE)
Equipment Trials
Make
Model
Turning Radius
Home Details
Home Type
-
Single-Family Home
-
Apartment
-
Condominium
-
Townhouse
-
Is the home currently handicap accessible?
Are there any factors (e.g. temperature, physical layout, surfaces, or obstacles) that will render the product unusable in the beneficiary’s home?
If yes, specify:
Does the patient’s home provide adequate access between rooms, maneuvering space, and surfaces for the placement of mobility equipment?
If no, describe:
Area Measurements
Provide measurements (length and width) for the following rooms (if applicable):
|
Area |
Measurements |
|---|---|
|
Bathroom |
|
|
Bedroom |
|
|
Living Room |
|
|
Kitchen |
|
|
Hallways |
|
|
Doorways |
|
Certification
I, the supplier, have thoroughly evaluated the patient’s home and, based on the information gathered, confirm that the residence is suitable for the Mobility Assistive Equipment (MAE):
Name:
Date:
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