HAT Eval Rec Client InfoClientDateIn-Home Mobility StatusSelectAmbulatory (no device)Straight CaneQuad CaneHemi WalkerStandard WalkerRolling WalkerRollatorWC (dependent)WC (propels self)Power WCScooterTravel ChairOutside Mobility StatusSelectAmbulatory (no device)Straight CaneQuad CaneHemi WalkerStandard WalkerRolling WalkerRollatorWC (dependent)WC (propels self)Power WCScooterTravel ChairHousing TypeType of Dwelling?SelectHouse, Condo, TownhouseMobile HomeApartmentType of HouseSelect1 Level1 Level (plus basement)Split Level House2 Levels2 Levels (plus basement)Multi-Level HouseMulti-Level House (plus basement)Type of ApartmentSelectBasement Apartment (1 level)Ground Floor Apartment (1 level)Second Floor Apartment (1 level)Apartment Building (3rd floor or higher, 1 level)Multi-Level ApartmentWhat Levels of Home are Used?Main FloorUpper LevelLower LevelBasementOther (see comments)Where are Vehicles Parked?SelectNone NeededAttached GarageSeparate GarageAttached CarportStand Alone CarportDriveway (uncovered)Street Parking Parking LotParking GarageAny Sidewalk, Driveway Problems?YesNoCheck Any Sidewalk, Driveway ProblemsUnpaved drivewayUneven driveway pavementNarrow DrivewayNo sidewalkUneven sidewalk pavementUphill sidewalk to homeDownhill sidewalk to homeObstacles on SidewalkSteps on sidewalkPoor lighting outside homeUnable to use elevatorUnable to open lobby doorOther (see comments)Does Client Perform Any Outdoor Tasks?Retrieve mail outsideTake pet outsideTake out trashOther (see comments)CommentsMost Used Entrance to HomeWhere is the Most Used Entrance?SelectFront DoorBack DoorGarage/CarportSide DoorOtherAre There Steps at this Entrance?YesNoNumber of Steps at this Entrance? *Any Problems with Steps?YesNoCheck Any Problems with StepsToo weak to climb stepsNo handrailsToo steepToo narrowSlippery surfaceObstacles on porch or landing areaBottom landing area too small to pivotTop landing area to small to pivotOther (see comments)Is There a Ramp?YesNoLength of ramp (feet) *Any Problems with Ramp?YesNoCheck Any Problems with RampToo weak to use rampNo handrailsToo steepToo narrowSlippery surfaceObstacles on rampToo longNeeds repairOther (see comments)Any Problems Opening Door?YesNoCheck Any Problems Opening DoorThreshold at door (<3 inches)Additional screen door interferesUnable to slide doorDoor too heavyCan’t insert keyCan’t turn knobOther (see comments)CommentsSecondary Entrance/Exit to HomeIs The Secondary Entrance Used?YesNoLocation of Secondary Entrance to HomeSelectFront DoorBack DoorGarage or Carport DoorSide DoorOther (see comments)Are There Steps at this Entrance?YesNoNumber of Steps *Any Problems with 2nd Steps?YesNoCheck Problems with Secondary StepsToo weak to climb stepsNo handrailsToo steepToo narrowSlippery surfaceObstacles on stepsOther (see comments)Is There a Ramp at this Entrance?YesNoLength of Secondary Ramp (feet) *Any Problems with 2nd Ramp?YesNoCheck Any Problems with 2nd RampToo weak to use rampNo handrailsToo steepToo narrowSlippery surfaceObstacles on rampToo longOther (see comments)Any Problems Opening 2nd Door?YesNoCheck Any Problems Opening 2nd DoorAdditional screen door interferesCan’t insert keyCan’t operate handleToo heavyCan’t use sliding doorOther (see comments)CommentsThird Entrance/Exit to HomeIs The Third Entrance Used?YesNoLocation of Third Entrance to HomeSelectFront DoorBack DoorGarage/CarportSide DoorOtherAre There Steps at this Entrance?YesNoHow Many Steps at this Entrance? *Any Problems with Steps?YesNoCheck Problems with 3rd StepsToo weak to climb stepsNo handrailsToo steepToo narrowSlippery surfaceObstacles on stepsOther (see comments)Is there a Ramp at 3rd Entrance?YesNoLength of Ramp (feet) *Any Problems with 3rd Ramp?YesNoCheck Any Problems with 3rd RampToo weak to use rampNo handrailsToo steepToo narrowSlippery surfaceObstacles on rampToo longOther (see comments)Any Problems Opening 3rd Door?YesNoCheck Any Problems Opening 3rd DoorAdditional screen door interferesCan’t insert keyCan’t operate handleToo heavyCan’t use sliding doorOther (see comments)CommentsBath/Shower SetupWhich Floor is Tub/Shower Located?SelectMain FloorUpper Level FloorLower Level FloorBasementTub/Shower Room LocationSelectEnter from Client’s BedroomEnter from HallwayEnter from Another BedroomCurrent Bath/Shower TypeSelectStandard Tub/Shower Combo (no door)Standard Tub/Shower Combo (with door)Step in Shower (no door)Step in Shower (with door)Roll-in-showerClaw foot tubAny Tub/Shower Grab Bars?YesNoCheck If Tub/Shower Grab BarsSame Wall as ControlsSide WallOpposite Wall from ControlsClamp-on Tub Grab BarAny Bathing Adaptive Equipment?YesNoCheck If Bath/Shower EquipmentShower bench (no back)Shower chair (with back)Tub transfer bench3-in-commodeHand held shower wandOther (see comments)Any Bathing Problems?YesNoCheck Any Bathing ProblemsGrab bars neededNot enough room to pivotToo weak to pull up on grab barTub wall too high to step overNo ant-slip matShower doors interfereFiberglass walls (no grab bars)Other (see comments)CommentsMost Used ToiletMain Toilet Floor LocationSelectMain FloorLower FloorUpper FloorBasementMain Toilet Room LocationSelectEnter from HallwayEnter from Client's BedroomEnter from Another BedroomOther Location in HomeType of ToiletSelectStandard Toilet (no adaptation)Elevated Toilet RiserOver Toilet Commode Chair Over Toilet Commode (with arms)3-in-1 ChairBedside CommodeAny Toilet Grab Bars?YesNoCheck If Toilet Grab BarBar Above Toilet TankRight Side (when seated)Left Side (when seated)In Front of ToiletOther (see comments)Any Toileting Problems?YesNoCheck Any Toileting ProblemsSpace too small for transferUnable to transfer on/offGrab bars neededToo weak to pull up on grab barToilet too lowToilet too highThrow rugs in pathwayCan't access toilet paperNeeds bidetOther (see comments)Any Problems Using Bathroom Sink?YesNoCheck Problems Using SinkCan’t reach faucet handlesCan't turn faucet handlesSpace too small for pivotGrab bars neededImpaired temperature sensationOther (see comments)CommentsSecondary ToiletIs a Secondary Toilet Used?YesNoSecondary Toilet Floor LocationSelectMain FloorUpper FloorLower FloorBasementSecondary Toilet Room LocationSelectEnter from HallwayEnter from Client's BedroomEnter from Another Bedroom2nd Toilet TypeSelectStandard Toilet (no adaptation)Elevated Toilet RiserOver Toilet Commode Chair Over Toilet Commode (with arms)3-in-1 ChairBedside CommodeAny 2nd Toilet Grab Bars?YesNo2nd Toilet Grab Bar Location?Bar Above Toilet Tank Right Side (when seated)Left Side (when seated)In Front of ToiletOther (see comments)Any 2nd Toilet Problems?YesNoCheck Any 2nd Toilet ProblemsSpace too small for transferCan't transfer on/offToo weak to pull up on grab barGrab bars neededToilet too lowToilet too highThrow rugs interfereCan't access toilet paperNeeds bidetOther (see comments)Any Problems Using 2nd Bathroom Sink?YesNoCheck Problems Using 2nd SinkCan’t reach faucet handlesCan't turn faucet handlesSpace too small for pivotGrab bars neededImpaired temperature sensationOther (see comments)CommentsBedroomAny Bed Transfer Problems?YesNoCheck Problems with Bed TransfersBed too low for transferBed too high for transferLimited space around bed to pivot Needs bedrailFurniture / obstacles in pathOther (see comments)Any Other Barriers in Bedroom?YesNoCheck Any Barriers in BedroomNarrow doors to enter/exitFurniture obstaclesThrow rugsLimited space around bed to pivotDifficulty accessing light switchesDifficulty accessing curtains/shadesDifficulty accessing closetOther (see comments)CommentsMoving Around the HomeAny Problems Moving Around Home?YesNoCheck Problems Moving Around HomeNarrow doorways/entrywaysFurniture / other obstaclesThrow rugs in pathwaySunken floor(s) with stepsPoor lightingDifficulty accessing light switchesPets wandering Other (see comments)CommentsInside StairwaysDoes Client Use Any Stairways Inside Home?YesNoWhich Stairways Does Client Use?To Upper LevelsTo BasementBoth Up/Down (Split Level Home)Any Problem With Upper Level Stairs?YesNoNumber of Upper Level StepsCheck Any Up Stairs ProblemsToo weak to climb stairsUnable to grip handrailNo handrailToo narrowObstacles on stepsSlipperyPoor lightingSteps not deep enoughPets wandering Other (see comments)Any Problem With Basement Stairs?YesNoNumber of Basement StepsCheck Any Basement Stairs ProblemsToo weak to climb stairsUnable to grip handrailNo handrailToo narrowObstacles on stepsSlipperyPoor lightingSteps not deep enoughPets wandering Other (see comments)Any Problem With Split Level Stairs?YesNoNumber of Split Level StepsCheck Any Split Level Stairs ProblemsToo weak to climb stairsUnable to grip handrailNo handrailToo narrowObstacles on stepsSlipperyPoor lightingSteps not deep enoughPets wandering Other (see comments)CommentsLiving Area of HomeAny Problems In Living Area of Home?YesNoCheck Any Problems in Living AreasCan't transfer to an easy chairCan't transfer to couchFurniture/obstacles in pathThrow rugsCan't access phoneCan't access light switches Can't open shades/curtainsCan't open windowsOther (see comments)CommentsCooking/Dining AreaAny Problems In Cooking/Dining Area?YesNoCheck Any Problems in Cooking/Dining AreaDining table too highDining table too lowCan’t access sinkCan’t access refrigerator Can't access microwaveCan’t access stovetopCan’t access ovenLimited counter spaceCan’t access pantryOther (see comments)CommentsLaundry/Utility RoomAny Problems In Laundry/Utility Room?YesNoCheck Any Problems in Laundry/Utility AreaCan’t access sinkCan’t transport laundryCan’t access top load washerCan’t access top load dryerCan’t access shelf/cabinetCant access electrical panelOther (see comments)CommentsComplete the ReportCommentsEvaluator NameHow Was Eval Completed?SelectOn-site at Client's HomeBy Client's ReportBy Caregiver's ReportEmail AddressGo to Report Summary