Occupation-based Home Assessment Client NameTnner Vayvosy Date of Assessment; Py/RP/i4 Type of Housing: house X___ apartment mobile/motor home. Other__ Residents inhome: TowcerQilosee Area outside and immediately surrounding the home: ‘What occupations, if any, take place in the area immediately surrounding the home epee the garage? BBBing, tadting at patio, Oardaning aking vacuum Taking Qavrhage to Curb - yrenny 3 9 Tewam Teen) CGR) Cavemen © GREP ROUS & Stepping, Stones Porch/Patio/Balcony/N.A. Surface material: CUNMQX\T Number of stairs: NIA, Height of stairs: NIA, Railing present (location, height, ease of use): N19) Type and width of door to area: Sliding glass Goor ; LU‘ wide. Type of furniture/ease of use; (alQ4S TOP PAL table € + Chairs T arrests. LGM Wt CHANTS, 2aSY TO Move dnot lw to giwund. i eee of : A NGRFSWIEEN SUB REM MS Bugk: aU high (lace € easy access) rd Yar Maictenanes required: Raking voRuMIng washing \auun © hose. Weed ‘ng How maintenance is completed currently: “JONner & JOsee UWE WOODEN FAKES fo rake, ieaves &pine needles, vacuum t 0. Shop vacuumMaspray E a Gard Nove. Equipment/activities pre eine hobby, work, machinery): BB hounee chairs & patio set Ease/efficiency of use of equipm BBOIS CAS) 49 ULE C PUR) Dutton to Light Chairs are extremely Want. Garage/worksho; How many cars: | (| Car garage) Proximity of cars to entrance: 5! Number and height of steps from garage to entrance: | step (4h gn)Railing present (location, height, ease of use): N\A) Storage systems: QApOOAICAS & SMES Ease/efficiency of use of tools/equipment: QLiprretyt 8 tools are 208U To acQuice HeCAUse TeY Are oanzed on tne Sheivesdin Cupboards . Ways to improve occupational performance, improve mobility, and/or improve safety in area immediately surrounding the home? Put Solar lights by yada & Stepping stones To light potrucouys. Put ratings or handles by doorways CO. Step. Front Entrance Number and eightofsteps 2. Steps (B" High each) Railing present (location, height, ease of use): (\\ |, Surfaces: CEMENT Steps 4 Inside LMMtance & tile Types of knobs/locks: RONG] Met KN’ | deadbolt lock Width of door: 35" Wide Back Entrance Number and height of steps: NI] A, Railing present (location, height, ease of use):: N\A Surfaces: Cement pactio; Wood Flour inside Types of knobs/lacks: [p"" Wooden NANIE; SMAI METAL lAtCh to WK Width of door: (y Wile. ‘Any concerns with safety/ease/convenience of entering the home? Front gntrance: Nay doorway &sereen door be Plliavesve i) “ey AOCK enhance: wicie cloor LMtranceKitchen List all occupations that take place in the kitchen and the primary users of this space: Primary User: Joee Food preparation cooling, 0 ; AKING WOSMING Ashes i Gisrwnashor 8 sorting . vel 3 J Width of doorway into kitchen: 53 wide Height of kitchen dining table: 3 ("” nign Height of countertons: 35" iq Continuous surfaces for siding objects? YES | 2 long, counter Fops on born type of stove:(1. OS sides OF kitOnen types and location of controls on stove/burmers: Fro + PUSH BTU FUNC) Koos Types of controls on oven: E\ECHric. louttons Height of oven: 35, “high ctfort needed to open/close oven: (DEM ~2ANFEICLAt (NOW 14 coor) Close — SPrINg door To Netp Chose. Are pote/pan ge heawy on do they 1 hot? ANN METALS ORT Very WoT Type of retreerstor-Ty) Freezer Refriger ator Height of handles and refrigerator shelves: WOYYALLS 233° /48" Depth of shelves: ON" GRO Dishwasher controls: Front button S case of loacing/unloading: COS\Y | WOCOACA NEXT TO Sunid. Lower Snel 18 Vike more difFicLur. Ease of transporting items: Gan sic actoxs paner dorwous Lgs/switches: height, : 7 3puige aren" 2 liane smurches or uu" vara DY doy ARE AONE ili 7 5 nization, amount): coor SRAP RGAE RAE ws RanWies. LOR OF stOraae. DME typically used in this area: Non mobility, and/or improve safety in kitchen area? ways to improve occupational performance, improve Stepping stool to reach shelves, & remove, Kitchen rugBathroom Occupations that take actin the master bath TOL Le ANG, SOARING, Groom (nour & q\ } owing) brushing teeth Anutting ‘Contacts ne "9 30"wide Flooring WV & ngs Types of faucets atsink: Yee” (Qoes Up AG own) Types of faucets in tub/shower: ROUAC, KAOID Wich You turn Non-skid surface in tub/shower: NO. Height of step into tub/shower: 13" iQ, Height of toilet: |p" Wigh, Type of lever to flush: |" \ayey- Location of toilet paper: (EEE OF Turlet ON WALI Heind Toilet Pugsewiches:4. GAY switch Mu"hiqh 4 not plug 43" nid Height of miror: 45" high Cupboards (height, type of handle, organization): | CUIpDOAIA Gt Yio" high ino handig DME typically used in this area: A} Ways to improve occupational performance, improve mobility, and/or improve safety in bath area? Place Torlet Paper tn Front of Tovlet more Plugs, increase, Nigwring, 8 dcid No-skia surface tn SMUWer , Bedroom Occupations that take place in the bedroom area: Doorway width: 30 "Wide Type of door/knob to access closet: RON Metal KNOD For bedroom & Height otcontn Zrods: 64359" nin Type of handles, ease of use of Dresser drawers: SMAN| TOWN KNOOS drawers \ ACN anization of storage/ease of finding items? organized! 6 sr OF clotnes - Crewdect & tends to be GAFEICLALE 1D Flin) ems .Height and ype of ightines ON CEILING; IQrit C fan, & becl side lamps Ease of access to lighting by the bea: Fauir ly Lasy Nut has smatt Knole You tun OME typically used in this area: f\ | AY Ways to improve occupational performance, improve mobility and/or improve safety in bedroom area? WEL \YQHEING Living room Occupations that take place in the living room: Watcly TV visit © Farmvy & frends . Doorway with: AQ)" Wi ge, Most used furniture (type and height): LUN S@Ocr 71" Wighy COUCH 171" High Locations and Ease of access to electronics: REMOAES WN Front OF COUCH on CoFeE Ne ners controls of window coverings: Ho ZONAL BiINAS C Strings f Gen & 2. Types of controls to open/close windows: W\NGOUIS S\tChc, verticatty ino handles Storage (type, access, organization): BOOKCASE AGALNS + WALI DME typically used in this area: |\} | Ways to improve occupational performance, improve mobility, and/or improve ease of use in living room area? \WCYPASC. Ugnting leaning Laundry (front/side load, controls, storage of detergent) hye fru sport € canals GT 7 YO! srg, 2 uaboares SEINE aster Baruer Can he dicFica® to reach wien on Top shelf . Locatect Convianentiy, & only Nos laundry supplies tr keep organized . Garbage removal bags, proces, transport Remove. fram trosh Cons wy NaknALMS A Kitchen, Fake oUt To Cprage. FATWQh WAANdry Tw . ON weangonyy dproage Cans faker out of garage & placed’ on Street in Front of House . (Small cecline in drive-vEquipment (vacuum, mop, broom, dustpan): Vacuum oreo dust pan, swi ffer wet jet Ways to improve occupational performance, improve mobility, and/or improve ease of use related to cleaning? LIAKTEY VaCULY) ,WeHer Storage For eaprpment Other considerations Ease of access to communication within and throughout the home: Eosy, very oped Flour plan Access and ease of use of Thermostat: occa) dowrciats ov WOW Neigins SY” nigh Touch screen can be difficutt t> Ose. Access to Community Transportation: There is & Us stop a blocks daw From my neiqnoorhoad \y -Aceess to grocery Store, drug stor, etc 7 » Fresh and Eosy'is dernss the Street & A olock down “walgreens” & Ssimtths "1S © /2 mile Pets in the home and any related safety concerns: dogs . | is a Puppy & so TOYS get tet On Flour causing a tripping Presence of environmental hazards (rugs, cords, obstacles in major pathways, etc.): Anere 180. FUG 1 dining, Yon, aF Front entry wor, & wh vartehen There ore No rds on Flour. The areas a tox Wnere file & wood Flos meet mony Couse OQ Trppma Noeard The. stars ore steep & word winiclh tan become Slippery & be a fall risk. There 19 ONY MUNG OF | Side OF the SFAirs .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. » Dut rauung or woth sides of the Stairs. Always a grrk sugy 9 2 PUt NOMFSIIP TACKON (nM QM Showers ya! s.increase. living roy) iqnting Onvy laps are urventy Wy FOO 4 Put Nandies on Cupocarc’s Mrugnowr house s Pronde more stage ot a {eve that doesnt require. a steyqping SHOD] . - Crstia 2asren CLs Additional recommendations: Tne. doo handles can ve changpe) TO levers IF diFfiCLUy E round Knows & a Counter top trcrowaye. JE URFICLLL Fencning. Remove (Lgs TO decrease. Chance. for Falls ALP apprepriaks UEC bo PB sepety, ¥ Ying USK Y rmprose Pony rrathaneed S you hare Warr cdys7 gat Occupational Therapist Name Printed: OSCE, LUNCKAUISY Signature: Qeen Anda nfs vate andrine: BABI4 Ot IFO