Recommendations Client InfoClientDateIn-Home Mobility StatusOutside Mobility StatusHousing TypeType of HomeHouse TypeApartment TypeLevels of Home UsedVehicles Parked?Sidewalk, Driveway ProblemsOutside Tasks PerformedDriveway, Sidewalk CommentsDriveway, Sidewalk RecommendationsUse rollator because it has bigger wheels Repair any uneven pavement or fill cracksMain Entrance to Home (Most Used)Location of Main EntranceRecommendation for Uneven Sidewalk or DrivewayHave sidewalk or driveway repaired to eliminate bumps, cracks Use rollator since wheels are larger than FWWNumber of Steps at Main Entrance?Main Steps ProblemsRecommendation for Unable to Walk Up Steps to HouseHave ramp installedRamp Rec query paramInstall a rampLength of ramp (feet)Main Ramp ProblemsMain Door ProblemsMain Entrance CommentsSecondary Entrance to HomeIs the Secondary Entrance Used?Location of Second EntranceAre There Steps at Secondary Entrance?Secondary Steps ProblemsLength of Secondary Ramp (feet)Secondary Ramp ProblemsSecondary Door ProblemsSecond Entrance CommentsThird EntranceIs the Third Entrance Used?Location of Third EntranceAre There Steps at Third Entrance?Third Steps ProblemsLength of 3rd RampThird Ramp ProblemsThird Door ProblemsThird Entrance CommentsBath / Shower RoomWhich Floor is Bath Shower Floor LocationBath Shower Room LocationBath Shower TypeBath Grab Bar LocationsBath Adaptive EquipmentBath/Shower ProblemsBath/Shower CommentsMain Toilet (Most Used)Main Toilet Floor LocationMain Toilet Room LocationMain Toilet TypeToilet Grab Bar LocationMain Toilet ProblemsMain Sink ProblemsMain Toilet CommentsIs Secondary Toilet Used?Secondary Toilet Floor LocationSecondary Toilet Room LocationSecondary Toilet Type2nd Toilet Grab Bar Locations2nd Toilet Problems2nd Sink ProblemsSecond Toilet CommentsBedroomBed Transfer ProblemsBedroom BarriersBedroom CommentsMoving Around the HomeMoving Around Home ProblemsMoving Around Home CommentsInside StairwaysAny Inside Stairways Used?Which Stairways are Used?Number of Basement StepsBasement Stairs ProblemsNumber of Upper Level StepsUp Stairs ProblemsNumber of Split Level StepsSplit Level ProblemsInside Stairways CommentsLiving AreasLiving Areas ProblemsLiving Areas CommentsCooking / Dining AreaCooking Area ProblemsCooking/Dining Area CommentsLaundry / Utility RoomLaundry Area ProblemsLaundry Area CommentsComplete the ReportCommentsEvaluator NameHow Was Assessment Completed?Email AddressSend Report to Email