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Free Home Assessment Form Template

Free Home Assessment Form

Name: Free Home Assessment Form Template
Brand: Template.net
Availability: InStock

Home Assessment Form

Please take a few moments to complete this assessment.

Patient Information

Name

Date of Birth

Phone number

Email

Address

Type of Mobility Assistive Equipment (MAE)

Manual Wheelchair

Power Wheelchair

Scooter

Walker

Cane

Crutches

Equipment Trials

Make

Model

Turning Radius

Home Details

Home Type

Single-Family Home
Apartment
Condominium
Townhouse

Is the home currently handicap accessible?

Are there any factors (e.g. temperature, physical layout, surfaces, or obstacles) that will render the product unusable in the beneficiary’s home?

If yes, specify:

Does the patient’s home provide adequate access between rooms, maneuvering space, and surfaces for the placement of mobility equipment?

If no, describe:

Area Measurements

Provide measurements (length and width) for the following rooms (if applicable):

Area	Measurements
Bathroom
Bedroom
Living Room
Kitchen
Hallways
Doorways

Certification

I, the supplier, have thoroughly evaluated the patient’s home and, based on the information gathered, confirm that the residence is suitable for the Mobility Assistive Equipment (MAE):

Name:

Date:

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Home assessment process simplified with the Home Assessment Form Template on Template.net! This form’s editable sections are designed to capture critical data with ease, all in one place. Completely customizable, it suits various types of properties and assessments. Leverage the integrated AI Editor Tool to quickly adapt the template for specific client requirements or industry standards!