Occupation-based Home Assessment Client Name: LW. {nie Date of Assessment:_4)/|/ 4 Type of Housing: house. apartment_V“__ mobile/motor home Other. Residents in home: D ovo ants 21,24 2: ‘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? Néqnbortyod Childe play 1 aass Suceunding apartment, Neghlors Wak dogs'in QOS 1 + People walk + dam Heir Crs, Porch/Patio/Balcony/N.A, Surface material: Comet Number of stairs: 0) Height of stairs: N|ft Rallng present (locaton, height, ease of use): HON, wiays aiouncl balcony Type and width of door trea: Shing lass dane SH x Bin wide ‘Type of furniture/ease of use: NF Plugs/switches (location, height, ease of use): N/A Maintenance required: 5 How maintenance is completed currently: DY MAintentance woiers fiom agactiment cumnplex Equipment/activities present (play, hobby, work, machinery): CHiildyéy1 playing, + cog waters Ease/efficiency of use of equipment: N|ft Garage/workshop How many cars: NIA Proximity of cars to entrance: N\¥t Number and height of steps from garage to entrance: NFRailing present (location, height, ease of use): N\ft storage systems: A Ease/efficiency of use of tools/equipment: N\ Ways to improve occupational performance, improve mobility, and/or improve safety in area immediately surrounding the home? Nit Front Entrance Number and height of steps: | StNS leadiog te froth entvants dain bigh by Bin wide faling present location height, ease of se): Meta Yang 4oin high Surfaces: Meal valing, CLM stetu's Types of knobs/locks: lever handle 3 Z deadbett leew Width of door: 3le if Back Entrance Number and height of steps: NI ft Railing present (location, height, ease of use|:: N\|ft Surfaces: N\A Types of knobs/locks: N\A Width of door: N\A Any concerns with safety/ease/convenience of entering the home? Many Staivs 4s enhianen of door ¢ 4 tgnttg ot nightBathroom alubagh Occupations that take place in the master bath: gyeoieg, 0 olen, Smiubes Width of doorway: 27901 Flooring: + water Viet waits + ons for cad Types of faucets at sink: two Awrst F098) One oy id wi Types of faucets in tub/shower: yt Awse E00 fs Non-skid surface in tub/shower: és, ula Wus (aug (UST? suslots at trtnm eth Height of step into tub/shower: |(yw Height of toilet: Gi" Type of lever to flush: lee {14519 Location of toilet paper: (idctl Nurt +> Toker Plugs/switches: ‘pug weed cuxt to Sik F in tall voor wv 20 gaurd; tel PLE 1s bin 40) Height of mirror: ies toed Cupboards (height, type of handle, organization): 20\, No naride, wwels + Cleary saghis S Mies reetaly gan ete anh AOA Medien tubnt 3m Setin nde are Vere pats i OnE typically Used in thi area: Nj ‘Ways to improve occupational performance, improve mobility, andor improve satey in bath area? Play. bathmat outside of snower +s eaticin eka wank oe paewent falls wun uit MOWED og Bedroom Occupations that take place in the bedroom area: S\eed , study ) dlessine Doorway width: 27.510, Type of door/knob to access closet: Kwioved coor ty waikin elact ¢ NO wondte Height of closet rod: (1 wiehes Type of handles, ease of use of Dresser drawers: Gra! Gucular Litds, Tae on enon ALLEY, Kegan RECA of, jvaive's dant sls welt Organization of storage/ease of finding items? 4)il.A® shut. Sits, sioeak, coals ae ai tg ae oud pene Bares ave-hloied + laid 1 Howes on 4g of shel Hts abe clock vod. enves axe v0 BNE on Alay, Purses AIS? Qe oat flow,kitchen List all occupations that take place in the kitchen and the primary users of this space: Maal wep, eating, ‘Studying at tikchen too Width of doorway into kitchen: 49 i: Height of kitchen dining table: &y.510 Height of countertops: Y 1 Continuous surfaces for sliding objects? Yes, Grund KACIT sink + Stove Type of stove: lee Types and location of controls on stove/bumners: Kyoko tsk La iacated on Nate Shute Tyres of controlson oven: SN tttons on HUCK. oF Show te cor eaneiatave oF EN Height of oven: 3s-iny Effort needed to open/close oven: Minimum effort veined Are pots/pans too heavy or do they get too hot? ove (aug Seilet Lecownes recy) Tull, Pan Nundes nave Mower covering «de ner det Het Type of refrigerator: fie¢eey oxi 4g fortion Z ebgvatey on fastens qortiun Height of handles and ref shelves: Aree Mand le ier planes ng eter shee feu hans ‘Bin yom gyound, Depth of shelves: 2/9. ‘ Dishwasher controls: Thist Krolbs Ease of loading/unloading-fy (ace a waist level mating ea 40 loadfunkod. Betton 100K very luo AY gycuund mating’ more iF beause person mist bend a WOis ts Veco dishes Ease of ing i 5 Hue Cubats and toloke ele ta since SERRE TERRES MS IN, Ha sa ah i aa Ye Plugs/switches; height, ease of use: 3 in, €451/ atess KECK looted on open wall space © Meth ot Caen Wceggie SON Hd fen wal sgt © neta Storage (ability.to reach, handles, organization, amount): 14 calonets, oliertt whale +> cecaen Hen7s in Saute West CAG Erion ory COMO te gt hese aM, “POS Ces Wada WAQah carck iy Ste; cents ae 1 A, r OME typically used in thivereayif aoe Fai nal keen Ways to improve occupational performance, improve mobility, and/or improve safety in kitchen area? Uae sty shot te Valen yi Shut 0 igusst CabMUe + plate Narmsiig weg 1 Aen of Faun Sin te cote 8 workfaint is a fig Swe ASin oAF ground, coin lgatsorch, for ceang ligirt 19.4 Fig ol Tae or oe eke eee eecbay hgnt by cast? A dusk larg 00 Fight located Ease of access to lighting bythe bed: [ginko nian ocwsie Frew) bad, Gtr Kghts fot anhanGs and satan ang Tay ASE” A ely esas Horm die uns ne Om yay used in ths aes ‘Ways to improve occupational performance, improve mobility and/or improve safety in bedroom area? ont Shoes + qurses in Clg} +e allo fy Moe Wate Saco + ¥ Charee ot fgg or falling, iving room Occupations that take place in the living room: SKC watanag ty, Yeading, Ox Doorway width: 3601 from alia Yon Nom dining room Most used furniture (type and height): Couch Kin high, CoH ec tabla, sido tenes, (400 cusch,, emoky lowatid on Locations and Ease of acess to electronics: TV. duitctly W) trent of remot) Ap oF Wy DvD Wiayer Toedsica te siz of TY on yu-fieot Types and controls of window coverin Panels Cover Shae ass ov oy ad k-hat twist to en nds Jin Types of controls to open/close windows: Wo windows “mm lwinyran ‘just sfidily Jassdoor heading ‘Daatersreis one Hew Kon dole myran ‘s storage (type, access, organization): Cuct n Valley of of fuving voor © SneWes for eva +wwels, ¥ Towels, Feilet Pager © bead Geuncs. DME typically used in this area: .y/ Ways to improve occupational performance, improve mobi, aoe improve ease of use in living room area? THe 15 Mo Caituy light: 17 He livittyyaom , AA. vas only ane small daa fame + om randy Jam) that does ne aoe sae Yi frting act Mgnt fy Sudling, o seach Cleaning: on Date a wasiar “ difer, Deter Laundry (front/side load, controls, storage of detergent: vad Waster, front adeload ayer, Go¥h er ere on swelf abrout drier Supplies (able to reach, organization, location] Dakin On SAP dane ciger ‘eteaaked Slgty ack oF reaan oF client fauge hase un aa votre Bn vitewen, flastictrasn 11 i logted under tive SINE: Lage dupes lotcitec! a4 away hon apartment tort cleerEquipment (vacuum, mop, broom, dustpan):, VORuuir loud wi Walloon clit. OUST pan, lacorn + map fecattad ia founds coon Ways to improve occupational performance, improve mobility, and/or improve ease of use related to cleaning? Ut a Seep Shol to Yau dotcragit in (aundey Youn Other considerations Ease of access to communication within and throughout the home: “The gral AfOHNUT < Close promaty oF Fitcten, living reo + batho allow fv Conmmnuricee tious is iA Walt to Near raat Enaokiny” whan i Hee 1akfhavm 7 bate bedeorry Access and ease of use of Thermostat: Thermostat 15 looated w~-He Pathway which & mtu niddle of the auartment. Th bon “e wall Just Betows chest evel miking ersy oh Kea att a easily aceesabke Access to Community Transportation: [A Access to grocery Store, rug store, etc.: es seen ‘ona ey aewss the sheet thave are Wary grocery Shves vethin a ual Pets in the home and any related safety concerns: 4\/j4 Presence of environmental hazards (rugs, cords, obstacles in major pathways, etc): Nip‘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. “uN a. 4, Sth fu fx ene Leta + JaALIEY Your te help Safely v€acsn ems 2 onerre syns We Clot wm evdarte > warring, qua + & potental fov fi at hgering I Iemigyor alae fev Inorvinre ov reading Yea Patt GEE waa won-siy tugs et Wns jut tds spower te * ulen wrluss woe + (revert falls 5. Add Nen-siy wg under Wt) sink *6 Present week tun geen on foot +0 ¥ fall's ‘Additional recommendations: Signature: Occupational Therapist Name Printed: on Aye 2 Date and time:_4 ft []4 4p