Recommendations – Discharge Guide

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Discharge Guide

Home Assessment Tool

Recommendations

Recommendations

Client Info

Client

Date

In-Home Mobility Status

Outside Mobility Status

Housing Type

House Type

Type of Home

Apartment Type

Levels of Home Used

Vehicles Parked?

Sidewalk, Driveway Problems

Outside Tasks Performed

Driveway, Sidewalk Comments

Driveway, Sidewalk Recommendations

Main Entrance to Home (Most Used)

Location of Main Entrance

Recommendation for Uneven Sidewalk or Driveway

Have sidewalk or driveway repaired to eliminate bumps, cracks

Use rollator since wheels are larger than FWW

Number of Steps at Main Entrance?

Main Steps Problems

Recommendation for Unable to Walk Up Steps to House

Have ramp installed

Ramp Rec query param

Length of ramp (feet)

Main Ramp Problems

Main Door Problems

Main Entrance Comments

Secondary Entrance to Home

Is the Secondary Entrance Used?

Location of Second Entrance

Are There Steps at Secondary Entrance?

Secondary Steps Problems

Length of Secondary Ramp (feet)

Secondary Ramp Problems

Secondary Door Problems

Second Entrance Comments

Third Entrance

Is the Third Entrance Used?

Location of Third Entrance

Are There Steps at Third Entrance?

Third Steps Problems

Length of 3rd Ramp

Third Ramp Problems

Third Door Problems

Third Entrance Comments

Bath / Shower Room

Which Floor is Bath Shower Floor Location

Bath Shower Room Location

Bath Shower Type

Bath Grab Bar Locations

Bath Adaptive Equipment

Bath/Shower Problems

Bath/Shower Comments

Main Toilet (Most Used)

Main Toilet Floor Location

Main Toilet Room Location

Main Toilet Type

Toilet Grab Bar Location

Main Toilet Problems

Main Sink Problems

Main Toilet Comments

Is Secondary Toilet Used?

Secondary Toilet Floor Location

Secondary Toilet Room Location

Secondary Toilet Type

2nd Toilet Grab Bar Locations

2nd Toilet Problems

2nd Sink Problems

Second Toilet Comments

Bedroom

Bed Transfer Problems

Bedroom Barriers

Bedroom Comments

Moving Around the Home

Moving Around Home Problems

Moving Around Home Comments

Inside Stairways

Any Inside Stairways Used?

Which Stairways are Used?

Number of Basement Steps

Basement Stairs Problems

Number of Upper Level Steps

Up Stairs Problems

Number of Split Level Steps

Split Level Problems

Inside Stairways Comments

Living Areas

Living Areas Problems

Living Areas Comments

Cooking / Dining Area

Cooking Area Problems

Cooking/Dining Area Comments

Laundry / Utility Room

Laundry Area Problems

Laundry Area Comments

Complete the Report

Comments

Evaluator Name

How Was Assessment Completed?

Email Address

Discharge Guide

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