Home Assessment Tool Welcome!The Home Assessment Tool (H.A.T.) Fill in all the info - then email yourself a completed PDF report when finished. Note - if you don’t see the email -check you spam folder. Important!! Don’t use the back button on your browser while filling out the form - you will lose all your work!Only use the "Previous" and "Next" buttons to move thru the form. Press “Finish Report Later” if you want to stop working on the form and come back to it later. 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 ChairMobility CommentsHousing SituationHousing TypeHouse, CondoApartmentMobile HomeMobile Home DetailsSelect1 Level1 Level with Attached SpaceHouse/ Condo DetailsSelect1 Floor House2 Story HouseMulti-Level HouseSplit Level HouseApartment DetailsSelectFirst Floor ApartmentSecond Floor ApartmentMulti-Level ApartmentMulti-Story Apartment BuildingBasement ApartmentMain Vehicle Parking SpotSelectNot ApplicableAttached GarageSeparate GarageCarportDriveway (uncovered)Street ParkingParking LotParking GarageAny Problems Approaching Home from Outside?YesNoCheck Any Outside Approach ProblemsUnpaved drivewayUneven driveway pavementNo sidewalkUphill sidewalkDownhill 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/Exit?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 steps 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 DoorAdditional screen door interferesCan’t insert keyCan’t operate handleToo heavyCan’t use sliding doorOther (see comments)CommentsSecondary Entrance/Exit to HomeIs The Secondary Entrance Used?YesNoLocation of Secondary Entrance to HomeSelectFront DoorBack DoorGarage/CarportSide 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)CommentsMost Used ToiletMost Used Toilet LocationSelectEnter from HallwayEnter from Client's BedroomEnter from Another BedroomOther Location in HomeType of ToiletSelectStandard Toilet (no adaptation)Elevated Toilet RiserOver Toilet Commode ChairOver Toilet Commode (with arms)3-in-1 ChairBedside CommodeAny Toilet Grab Bars?YesNoCheck If Toilet Grab BarBar Above Toilet TankRight SideLeft SideIn Front of ToiletOther (see comments)Any Toileting Problems?YesNoCheck Any Toileting ProblemsSpace too small for transferGrab bars neededToo weak to pull up on grab barToilet too lowToilet too highThrow rugs interfereCan't access toilet paperOther (see comments)Any Problems Using Bathroom Sink?YesNoCheck Problems Using SinkCan’t reach faucet handlesSpace too small for pivotGrab bars neededImpaired temperature sensationOther (see comments)CommentsSecondary ToiletIs a Secondary Toilet Used?YesNoSecondary Toilet LocationSelectEnter from HallwayEnter from Client's BedroomEnter from Another BedroomOther Location in Home2nd Toilet TypeSelectStandard Toilet (no adaptation)Elevated Toilet RiserOver Toilet Commode ChairOver Toilet Commode (with arms)3-in-1 ChairBedside CommodeAny 2nd Toilet Grab Bars?YesNo2nd Toilet Grab Bar Location?No Grab BarsBar Above Toilet TankRight SideLeft SideIn Front of ToiletOther (see comments)Check Problems Using 2nd SinkCan’t reach faucet handlesSpace too small for pivotGrab bars neededImpaired temperature sensationOther (see comments)Any 2nd Toilet Problems?YesNoCheck Any 2nd Toilet ProblemsSpace too small for transferToo weak to pull up on grab barGrab bars neededToilet too lowToilet too highThrow rugs interfereCan't access toilet paperOther (see comments)Any Problems Using 2nd Bathroom Sink?YesNoCommentsBath/Shower SetupCurrent 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 tubTub/Shower Area LocationSelectEnter from Client’s BedroomEnter from HallwayEnter from Another BedroomAny 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 interfereOther (see comments)CommentsBedroomAny Bed Transfer Problems?YesNoCheck Problems with Bed TransfersDifficulty transferring - bed too lowDifficulty transferring - bed too highLimited space around bed to pivot with walkerLimited space for wheelchairNeeds bedrailFurniture obstaclesOther (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)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 wanderingOther (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 wanderingOther (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 wanderingOther (see comments)CommentsMoving Around the HomeAny Problems Moving Around Home?YesNoCheck Problems Moving Around HomeNarrow doorways/entrywaysFurniture obstaclesThrow rugsAdditional steps inside homePoor lightingDifficulty accessing light switchesPets wanderingOther (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 refrigeratorCan't access microwaveCan’t access stovetopCan’t access ovenLimited counter spaceCan’t access pantryOther (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 switchesCan't open shades/curtainsCan't open windowsOther (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 ReportAdditional Comments?Evaluator NameHow Was Eval Completed?SelectOn-site at Client's HomeBy Client's ReportBy Caregiver's ReportEmail Address *Send Report to EmailFinish Report Later
Functional Therapy ActivitiesFunctional Therapy Activities