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Discharge Guide
Home Assessment Tool
HAT Eval Rec
HAT Eval Rec
Client Info
Client
Date
In-Home Mobility Status
Select
Ambulatory (no device)
Straight Cane
Quad Cane
Hemi Walker
Standard Walker
Rolling Walker
Rollator
WC (dependent)
WC (propels self)
Power WC
Scooter
Travel Chair
Outside Mobility Status
Select
Ambulatory (no device)
Straight Cane
Quad Cane
Hemi Walker
Standard Walker
Rolling Walker
Rollator
WC (dependent)
WC (propels self)
Power WC
Scooter
Travel Chair
Housing Type
Type of Dwelling?
Select
House, Condo, Townhouse
Mobile Home
Apartment
Type of House
Select
1 Level
1 Level (plus basement)
Split Level House
2 Levels
2 Levels (plus basement)
Multi-Level House
Multi-Level House (plus basement)
Type of Apartment
Select
Basement Apartment (1 level)
Ground Floor Apartment (1 level)
Second Floor Apartment (1 level)
Apartment Building (3rd floor or higher, 1 level)
Multi-Level Apartment
What Levels of Home are Used?
Main Floor
Upper Level
Lower Level
Basement
Other (see comments)
Where are Vehicles Parked?
Select
None Needed
Attached Garage
Separate Garage
Attached Carport
Stand Alone Carport
Driveway (uncovered)
Street Parking
Parking Lot
Parking Garage
Any Sidewalk, Driveway Problems?
Yes
No
Check Any Sidewalk, Driveway Problems
Unpaved driveway
Uneven driveway pavement
Narrow Driveway
No sidewalk
Uneven sidewalk pavement
Uphill sidewalk to home
Downhill sidewalk to home
Obstacles on Sidewalk
Steps on sidewalk
Poor lighting outside home
Unable to use elevator
Unable to open lobby door
Other (see comments)
Does Client Perform Any Outdoor Tasks?
Retrieve mail outside
Take pet outside
Take out trash
Other (see comments)
Comments
Most Used Entrance to Home
Where is the Most Used Entrance?
Select
Front Door
Back Door
Garage/Carport
Side Door
Other
Are There Steps at this Entrance?
Yes
No
Number of Steps at this Entrance?
*
Any Problems with Steps?
Yes
No
Check Any Problems with Steps
Too weak to climb steps
No handrails
Too steep
Too narrow
Slippery surface
Obstacles on porch or landing area
Bottom landing area too small to pivot
Top landing area to small to pivot
Other (see comments)
Is There a Ramp?
Yes
No
Length of ramp (feet)
*
Any Problems with Ramp?
Yes
No
Check Any Problems with Ramp
Too weak to use ramp
No handrails
Too steep
Too narrow
Slippery surface
Obstacles on ramp
Too long
Needs repair
Other (see comments)
Any Problems Opening Door?
Yes
No
Check Any Problems Opening Door
Threshold at door (<3 inches)
Additional screen door interferes
Unable to slide door
Door too heavy
Can’t insert key
Can’t turn knob
Other (see comments)
Comments
Secondary Entrance/Exit to Home
Is The Secondary Entrance Used?
Yes
No
Location of Secondary Entrance to Home
Select
Front Door
Back Door
Garage or Carport Door
Side Door
Other (see comments)
Are There Steps at this Entrance?
Yes
No
Number of Steps
*
Any Problems with 2nd Steps?
Yes
No
Check Problems with Secondary Steps
Too weak to climb steps
No handrails
Too steep
Too narrow
Slippery surface
Obstacles on steps
Other (see comments)
Is There a Ramp at this Entrance?
Yes
No
Length of Secondary Ramp (feet)
*
Any Problems with 2nd Ramp?
Yes
No
Check Any Problems with 2nd Ramp
Too weak to use ramp
No handrails
Too steep
Too narrow
Slippery surface
Obstacles on ramp
Too long
Other (see comments)
Any Problems Opening 2nd Door?
Yes
No
Check Any Problems Opening 2nd Door
Additional screen door interferes
Can’t insert key
Can’t operate handle
Too heavy
Can’t use sliding door
Other (see comments)
Comments
Third Entrance/Exit to Home
Is The Third Entrance Used?
Yes
No
Location of Third Entrance to Home
Select
Front Door
Back Door
Garage/Carport
Side Door
Other
Are There Steps at this Entrance?
Yes
No
How Many Steps at this Entrance?
*
Any Problems with Steps?
Yes
No
Check Problems with 3rd Steps
Too weak to climb steps
No handrails
Too steep
Too narrow
Slippery surface
Obstacles on steps
Other (see comments)
Is there a Ramp at 3rd Entrance?
Yes
No
Length of Ramp (feet)
*
Any Problems with 3rd Ramp?
Yes
No
Check Any Problems with 3rd Ramp
Too weak to use ramp
No handrails
Too steep
Too narrow
Slippery surface
Obstacles on ramp
Too long
Other (see comments)
Any Problems Opening 3rd Door?
Yes
No
Check Any Problems Opening 3rd Door
Additional screen door interferes
Can’t insert key
Can’t operate handle
Too heavy
Can’t use sliding door
Other (see comments)
Comments
Bath/Shower Setup
Which Floor is Tub/Shower Located?
Select
Main Floor
Upper Level Floor
Lower Level Floor
Basement
Tub/Shower Room Location
Select
Enter from Client’s Bedroom
Enter from Hallway
Enter from Another Bedroom
Current Bath/Shower Type
Select
Standard Tub/Shower Combo (no door)
Standard Tub/Shower Combo (with door)
Step in Shower (no door)
Step in Shower (with door)
Roll-in-shower
Claw foot tub
Any Tub/Shower Grab Bars?
Yes
No
Check If Tub/Shower Grab Bars
Same Wall as Controls
Side Wall
Opposite Wall from Controls
Clamp-on Tub Grab Bar
Any Bathing Adaptive Equipment?
Yes
No
Check If Bath/Shower Equipment
Shower bench (no back)
Shower chair (with back)
Tub transfer bench
3-in-commode
Hand held shower wand
Other (see comments)
Any Bathing Problems?
Yes
No
Check Any Bathing Problems
Grab bars needed
Not enough room to pivot
Too weak to pull up on grab bar
Tub wall too high to step over
No ant-slip mat
Shower doors interfere
Fiberglass walls (no grab bars)
Other (see comments)
Comments
Most Used Toilet
Main Toilet Floor Location
Select
Main Floor
Lower Floor
Upper Floor
Basement
Main Toilet Room Location
Select
Enter from Hallway
Enter from Client’s Bedroom
Enter from Another Bedroom
Other Location in Home
Type of Toilet
Select
Standard Toilet (no adaptation)
Elevated Toilet Riser
Over Toilet Commode Chair
Over Toilet Commode (with arms)
3-in-1 Chair
Bedside Commode
Any Toilet Grab Bars?
Yes
No
Check If Toilet Grab Bar
Bar Above Toilet Tank
Right Side (when seated)
Left Side (when seated)
In Front of Toilet
Other (see comments)
Any Toileting Problems?
Yes
No
Check Any Toileting Problems
Space too small for transfer
Unable to transfer on/off
Grab bars needed
Too weak to pull up on grab bar
Toilet too low
Toilet too high
Throw rugs in pathway
Can’t access toilet paper
Needs bidet
Other (see comments)
Any Problems Using Bathroom Sink?
Yes
No
Check Problems Using Sink
Can’t reach faucet handles
Can’t turn faucet handles
Space too small for pivot
Grab bars needed
Impaired temperature sensation
Other (see comments)
Comments
Secondary Toilet
Is a Secondary Toilet Used?
Yes
No
Secondary Toilet Floor Location
Select
Main Floor
Upper Floor
Lower Floor
Basement
Secondary Toilet Room Location
Select
Enter from Hallway
Enter from Client’s Bedroom
Enter from Another Bedroom
2nd Toilet Type
Select
Standard Toilet (no adaptation)
Elevated Toilet Riser
Over Toilet Commode Chair
Over Toilet Commode (with arms)
3-in-1 Chair
Bedside Commode
Any 2nd Toilet Grab Bars?
Yes
No
2nd Toilet Grab Bar Location?
Bar Above Toilet Tank
Right Side (when seated)
Left Side (when seated)
In Front of Toilet
Other (see comments)
Any 2nd Toilet Problems?
Yes
No
Check Any 2nd Toilet Problems
Space too small for transfer
Can’t transfer on/off
Too weak to pull up on grab bar
Grab bars needed
Toilet too low
Toilet too high
Throw rugs interfere
Can’t access toilet paper
Needs bidet
Other (see comments)
Any Problems Using 2nd Bathroom Sink?
Yes
No
Check Problems Using 2nd Sink
Can’t reach faucet handles
Can’t turn faucet handles
Space too small for pivot
Grab bars needed
Impaired temperature sensation
Other (see comments)
Comments
Bedroom
Any Bed Transfer Problems?
Yes
No
Check Problems with Bed Transfers
Bed too low for transfer
Bed too high for transfer
Limited space around bed to pivot
Needs bedrail
Furniture / obstacles in path
Other (see comments)
Any Other Barriers in Bedroom?
Yes
No
Check Any Barriers in Bedroom
Narrow doors to enter/exit
Furniture obstacles
Throw rugs
Limited space around bed to pivot
Difficulty accessing light switches
Difficulty accessing curtains/shades
Difficulty accessing closet
Other (see comments)
Comments
Moving Around the Home
Any Problems Moving Around Home?
Yes
No
Check Problems Moving Around Home
Narrow doorways/entryways
Furniture / other obstacles
Throw rugs in pathway
Sunken floor(s) with steps
Poor lighting
Difficulty accessing light switches
Pets wandering
Other (see comments)
Comments
Inside Stairways
Does Client Use Any Stairways Inside Home?
Yes
No
Which Stairways Does Client Use?
To Upper Levels
To Basement
Both Up/Down (Split Level Home)
Any Problem With Upper Level Stairs?
Yes
No
Number of Upper Level Steps
Check Any Up Stairs Problems
Too weak to climb stairs
Unable to grip handrail
No handrail
Too narrow
Obstacles on steps
Slippery
Poor lighting
Steps not deep enough
Pets wandering
Other (see comments)
Any Problem With Basement Stairs?
Yes
No
Number of Basement Steps
Check Any Basement Stairs Problems
Too weak to climb stairs
Unable to grip handrail
No handrail
Too narrow
Obstacles on steps
Slippery
Poor lighting
Steps not deep enough
Pets wandering
Other (see comments)
Any Problem With Split Level Stairs?
Yes
No
Number of Split Level Steps
Check Any Split Level Stairs Problems
Too weak to climb stairs
Unable to grip handrail
No handrail
Too narrow
Obstacles on steps
Slippery
Poor lighting
Steps not deep enough
Pets wandering
Other (see comments)
Comments
Living Area of Home
Any Problems In Living Area of Home?
Yes
No
Check Any Problems in Living Areas
Can’t transfer to an easy chair
Can’t transfer to couch
Furniture/obstacles in path
Throw rugs
Can’t access phone
Can’t access light switches
Can’t open shades/curtains
Can’t open windows
Other (see comments)
Comments
Cooking/Dining Area
Any Problems In Cooking/Dining Area?
Yes
No
Check Any Problems in Cooking/Dining Area
Dining table too high
Dining table too low
Can’t access sink
Can’t access refrigerator
Can’t access microwave
Can’t access stovetop
Can’t access oven
Limited counter space
Can’t access pantry
Other (see comments)
Comments
Laundry/Utility Room
Any Problems In Laundry/Utility Room?
Yes
No
Check Any Problems in Laundry/Utility Area
Can’t access sink
Can’t transport laundry
Can’t access top load washer
Can’t access top load dryer
Can’t access shelf/cabinet
Cant access electrical panel
Other (see comments)
Comments
Complete the Report
Comments
Evaluator Name
How Was Eval Completed?
Select
On-site at Client’s Home
By Client’s Report
By Caregiver’s Report
Email Address
Go to Report Summary