Aging-in-Place Readiness Assessment Form

Basic Information

Name Age Address Phone Email

Is your home a:

Number of floors in your home:

Are there steps or stairs inside your home?

Yes No

Do you have a bedroom and bathroom on the main floor?

Yes No

Do you have grab bars in bathrooms?

Yes No

Is your home entrance accessible without steps?

Yes No

Do you have good lighting in all areas?

Yes No

Do you have family or friends nearby who can help?

Yes No

Do you use any home care or support services?

Yes No

If yes, please specify:

Do you have health or mobility challenges that affect your daily living?

Yes No

If yes, please describe:

Which daily tasks do you sometimes need help with?