Occupation-based Home Assessment Client Name: bate of Assessment: 4/1 7/14- Type of Housing: house____apartment_“__mobile/motor home. Other. Residents in home fey finite, Daw Slertdaacd, cas (clog) ‘What occupations, if any, take place in the area immediately surrounding the home and/or inside the eros NOM UO GALA ip UY Uoed AOL braing/eniting Ye ~ BiGLUOOLUC. Tecan; tnctne Grass Pavement) Other Porch/Patio/Balcony/N.A, Surface material: (OY\CAICL Number of stairs: JOU, Height of tis: NYA, Railing present (location, height, ease of use}: Y\OYUL Type and width aie eer 36 3S wid penung. w/ singe Type of furiture/ease of use: \OVLL Plugs/switches (location, height, ease of use|: V\QYL, | Maintenance reauired: /\() (AQ mouncunanu arwdvids ol sow maintenance m= none (Opt / oy, COLA) en Equipment/activities present (play, hobby, work, machinery}: NIA Ease/efficiency of use of equipment NIA Season 10 QL) How many cars: COYYLY\| Proximity of cars to entrance: J () conus uncowrldl Parlour (asperelung on avauab ) Number and height of steps from garage to entrance: N/ARallng present (location, height, ease of use): NY | A storage systems: N/A Ease/efficiency of use of tools/equipment: \Y i A Ways to improve occupational performance, improve mobility, and/or improve safety in area immediately surrounding the home? THUR OWL NO Wicd Wows nowcl, axtoLooL FOWwWALe wo wide 4 woul mauTtaued utrance JD LLOW Wir Nd tad OL OOstArwa: NAW Cour We Gololecl HH neectect but uricraag Front Entrance Number and height of steps: NOL Railing present (location, height, ease of use): WOPLL, setae: UpniUete > Jaaminacte. > cor pet (red. puLe) Types of knobs/locks: FING Aeadoolt € Lunwr Snandte Width of door: 26. 5S" saccemrance 9 (from Map ony One surtrance) Number and height of steps: N/A failing present (location, height, ease of use): [A Surfaces NIA Types of knobs/locks: | A Width of door: [ A Any concerns with safety/ease/convenience of entering the home? smo down ot OLooL Wuanotd; wuitbonc ma wn ig ancl: ‘ a CLODL SOMA SHLALLO & 0d" Jun Hugh ae Tempus (May, aut pening) Losing) eKitchen List all occupations that take place in the god and the primary users of this, cio Upc Aoi yeaa wou, rou a ga 0 ich ni ith CNA a etecay aes @ door t et. Height of kitchen dining table: ry" Height of countertops: 2/5 Continuous surfaces for sliding objects? ewe, & Ane ene Type of stove: 4. YUL Types and location of controls on $ velburers: B FOLIO UNO Types of controls on oven: (ig LOvit “ARCLNG, — Height of even: So" 4D) 100; 32" 10 NoncLLe Effort needed to open/close oven: WuniwuwuM Ae ptsfoans too hea ord they gt too a wag inom suede Type of refrigerator: FILL - 2L / ial), por {or) Height of handles and refrigerator shelves: S24 eo ee tye Depth of shelves: ((" uidge; (2" (hecwr top sett)’ / Dishwasher controls: fiore- faceg bndo 4 one switch Ease oFoading/untssing: NAG OLOACL "aie Easeot aspen tems: 0) OLN Prowryan Plugs/switches: height, ease of use: pluqp- AL | Light swt Q cme ten nnn gee Ip une urge syne OME ypcly used inthis ares: Any (ig Wide nough unto uacd Ways to improve occupational performance, improve mobility, and/or improve safety in kitchen area? WCLadel SAGE Neecleo| 10 I Oe apace, Stor Oppriances: “4 ee td he | (nave VIO nan Skid ating [cegping Wa | LBathroom Occupations that tke place inthe master bath: PULLING cLAxsaing, uN WOW 4 Width of doorway: 3A" Flooring: {qyyniunocc. Types offaucetsatsine-? yet \yuurchLto (aot g cDIdl) Types of faucets in tub/shower: | GWiveh Wind Non-skid surface in tub/shower: /\OYUL, Height of step into tub/shower: |[g"" Height of toilet: |S 6 ‘Type of lever to flush: |) wanoteetnee {DB of fw (OAtached 10 cabinet) 0 Plugs/switehes: teh sd Sure A feat C4 Height of mirror: Cupboards (height, type of handle, organization): dour dep 3" aS below epunzo beh a), are di DME typically used in this area: bone nena) 4 WO 7 iets 4 onus Ways to improve CONC performance, improve mobility, and/or improve Oluitten in bath area? outa, acol ties “Sho Mat to \y fuienntor jae Bearoom Occupations that take place in the bedroom area vunplng, Apactin ana, acuity, Doorway width: 2/4" Type of door/knob to access closet (Uoset n adnvoom); atandand lob Height of closet rod: (75 "" ¢ 34" (Laer vod) Type of handles, ease of use of Dresser drawers: FYVLLA CLL \urwod, drow! Organization of storage/ease of finding items? 108 “awe 4 WLU! Hppruicecl Yrougn daours drawers fide 2)Height and ype of ushtine: (LOA ECLO cat [fia ihre Ease of access to lighting by the bed: w/ in fin ac tT apetinedl a gC Now NOLL SIDS KUL OF CLuctber/obrrouiea; wale areas aoe wide Lary, LaUnging, per COAL ae My Doorway wiath: & " LWIA L Auen open any lost sed furniture (type and height): 20" ($+ 20" Most used furniture (type and height}: if Ce on ya tableg: 25° Locations and Ease of access to elecront-Ty dy emau Stand oppose couch; Marrs’ ce TO ACO ‘Types of controls to iy windows: oN AN Ows {hd wale Fabotid Cluguan Wen aet apie) DME typically used in this ar n Ways to improve occupational performance, improve mobility, and/or improve ease of use in living room area? CRUAL WOK spice logtune Youdn Fottomwn Cleaning: Laundry (front/side load, controls, storage of detergent): WSN TOP loa W| STOULCL Cucoue. (~(00" up) on sma ¢ cence dnmmt ag ee eu Ov Meg) 0 G inl; vacuum wos Usarund suppliea SUcl und irtdew Garbage removal (bags, process, transport: Can © Ondl kitchen ina wurst (2e Cwapored UN dumpster bIZ0 yaya aunass)irall cov Ro fidge Ways to improve occupational performance, improve mobility, and/or improve ease of use related to cleaning? (i CUAL 1 ppnow Ease of access to communication within and enivalsy the home: (JL GM Uovuruur carbon dvi tn hone Oe wi eters feat Ball ¢ veal Comin uict Oa Th ace, Un Maltway 0 L of Wing Yoon ~ 45" up ‘Access and ease of use of Thermostat: a te i ipioeognemert company sag iy, en WN tale, 2 pet Aas Un Jorge ma ce ral ok cya ip Ht reform porting. a in Witchen $2. batho No Lod in WOO | yore votuleuoay UN Spar BAUM Ade ae (wideSummary: List the top 5 modifications to the space that you fee! would have the biggest impact on improving occupational performance, mobility, and/or safety in the home. > AMO Wolo ee lutdwn 4, vaxvoome- > ADOUE Lyceare, dog typ [seupping ncaarol) 4,0 | -ncUaae image options Un Witch @ Larurclryg: ADM 7 (ue De UW Loses 1D be asin to acteag/ | ran NW ittine 7 * inna. Jonge ottoman un Luin, cdn to Vide \oektn? wole trace Additional recommendations: Provide MON-Mip meta Un two/mowere x2) Occupational Therapist Name Princes: DOU E. Goddard, OT-S Signatse; N= Dateand time: A(T [4 7:0 PM.PORTFOLIO