Home Modification Disability Assessment Sheet
Client Information
Name
Date of Birth
Address
Phone
Assessment Date
Assessor Information
Assessor Name
Profession/Role
Contact Details
Disability and Functional Details
Type of Disability
Functional Limitations
Assistive Devices (if any)
Assessment of Home Environment
Rooms/Areas Assessed
Area
Current Barriers
Recommended Modifications
Entrance
Bathroom
Kitchen
Bedroom
Living Area
Other
Summary & Recommendations
Summary of Assessment
Recommended Modifications & Priorities
Signatures
Client/Guardian Signature
Date
Assessor Signature
Date