Physical Therapy Home Assessment Sheet
Patient Information
Name
Date of Assessment
Assessor
Address
Contact Number
Home Accessibility
Entrance (Steps, Ramp, etc.)
Hallways (Width, Obstacles)
Doors (Widths, Thresholds)
Elevators (if applicable)
Living Spaces
Living Room (Furniture arrangement, Hazards)
Bedroom (Accessibility, Bed Height)
Kitchen (Appliance access, Workspace)
Bathroom (Grab bars, Toilet height)
Mobility and Safety
Mobility Aids Used
Lighting (Adequacy, Switch locations)
Floor Surfaces (Carpets, Rugs, Slip hazards)
Emergency Exits / Fire Safety
Recommendations and Plan
Suggested Modifications
Adaptive Equipment Needed
Home Exercise Program
Other Notes