Home Assessment Questionnaire
___ ___ Does your home have more than 1 level?
___ ___ Are there stairs by the home entrances or within the home?
___ ___ Do you have a bath tub?
___ ___ Are there grab bars in the bathroom?
___ ___ Is there a step into your shower? Is there a seat inside the shower?
___ ___ Is it difficult to raise up from the toilet because it is too low?
___ ___ Can you reach all shelving in kitchen cabinets safely?
___ ___ Do you have room to maneuver around your kitchen safely?
___ ___ Is your house well lit? Are there dark rooms or areas within your home that make it difficult for you to see objects/furniture?
___ ___ Are your doorways and hallways wide enough to accommodate a wheel chair or walker?
___ ___ Is there a fire extinguisher, fire alarm and carbon monoxide alarm located within your home?
___ ___ Are all handles on doors lever style handles?
___ ___ Are the oven knobs located on the front of the oven?
___ ___ Is your carpet pile ½ inch or less or berber style carpet?
___ ___ Do you have a front loading washing machine and dryer?
___ ___ Are there fluorescent lights in your laundry area?
___ ___ Are there any thresholds by doorways that are over ½ inch?
“Creating Your Home… For Life”
(407) 595-3342 Fax: (208) 567-9757 Email: Aginginplacesafely@yahoo.com