Stroke Rehabilitation Home Assessment Form

Patient Information

Patient Name Date of Birth Home Address Assessment Date

Home Accessibility

Entrance Accessibility (e.g., steps, ramp, railing) Doorway Widths (suitable for wheelchair/walker?) Hallway Accessibility

Living Space

Living Room Accessibility & Hazards Bedroom Accessibility & Hazards Bathroom Accessibility (grab bars, shower, toilet, non-slip features) Kitchen Accessibility & Hazards

Mobility & Safety

Mobility Aids (wheelchair, cane, walker, etc.) Potential Fall Risks (rugs, cords, clutter, stairs, etc.) Emergency Plan (contacts, exits, alarms)

Recommendations / Modifications

Recommendations for Home Adaptations

Assessor Name Assessor Signature