Occupation-based Home Assessment Client Name: _C.G.

___________________ Date of Assessment:___8/30/2012_____

Type of Housing: house __X___ apartment______ mobile/motor home______ Other______ Residents in home: __1_________________________________________________________
Area outside and immediately surrounding the home: What occupations, if any, take place in the area immediately surrounding the home and/or inside the garage? The client walks out to her car, waters plants, and takes out the garbage to the sidewalk curb Terrain: Incline Grass Pavement Other

Porch/Patio/Balcony/N.A. Surface material: N/A Number of stairs: N/A Height of stairs: N/A Railing present (location, height, ease of use): N/A Type and width of door to area: N/A Type of furniture/ease of use: N/A Plugs/switches (location, height, ease of use): N/A Yard Maintenance required: Minimal maintenance required. Client only has to water 4 small plants. How maintenance is completed currently: Plants are watered 3 days a week. Equipment/activities present (play, hobby, work, machinery): N/A Ease/efficiency of use of equipment: Equipment used for maintaining the yard includes a hose, which the client can easily reach & turn on/off. Garage/workshop How many cars: 1

Proximity of cars to entrance: 15 Number and height of steps from garage to entrance: 1 step, 5 Railing present (location, height, ease of use): N/A Storage systems: N/A- no storage systems present in garage Ease/efficiency of use of tools/equipment: N/A Ways to improve occupational performance, improve mobility, and/or improve safety in area immediately surrounding the home? To improve occupational performance & mobility, the car can be parked in the driveway or inside of the garage instead of on the curb. Installing an automatic garage opener control will also improve safety & performance, because it will prevent the client from manually opening & closing the garage door. No sprinklers or cracks in the sidewalk surrounding the home are present. Front Entrance Number and height of steps: 3 steps, 5 Railing present (location, height, ease of use): N/A Surfaces: Pavement Types of knobs/locks: Round metal door knobs / dead bolt lock Width of door: 3 Back Entrance Number and height of steps: 1 step 3 Railing present (location, height, ease of use): N/A Surfaces: Tile, cement, and gravel Types of knobs/locks: Round metal door knob / dead bolt lock Width of door: 32 Any concerns with safety/ease/convenience of entering the home? Concerns entering the home revolves around the safety of the back entrance. There is gravel & large bricks present that obscure the walking pathway. There is also a 3 by 3 square of tile leading to the door of the back entrance that has a slippery surface, which can potentially lead to falls.

Kitchen List all occupations that take place in the kitchen and the primary users of this space: Cooking/baking Cleaning (e.g. mopping, sweeping, dusting) Washing dishes Eating Socializing

The primary user of this space is the client who lives alone. Width of doorway into kitchen: 42 Height of kitchen dining table: 28.5 Height of countertops: 35 Continuous surfaces for sliding objects? Continuous surface for sliding objects is limited. It is only present from sink to edge of counter. Continuous surfaces obstructed by sink & stove Type of stove: 4 top burner, gas stove Types and location of controls on stove/burners: The stove controls consist of 4 small knobs that are located on the front surface, directly below the stove top. They turn counter clockwise starting from high to low heat. Types of controls on oven: The controls of the oven are on a touchpad above the stove top. They are small, black, electrical buttons. Height of oven: 3 Effort needed to open/close oven: The effort needed to open/close the oven is minimal. It is lightweight & easily slides & . Are pots/pans too heavy or do they get too hot? Yes, some of the pots are too heavy & can get too hot. These pots are the larger pots that do not have any wooden or insulated handles. The client does not have any sensory or tactile deficits. Type of refrigerator: Top-freezer/mount refrigerator the fresh food compartment on the bottom & the freezer on top. Height of handles and refrigerator shelves: Handle to the food compartment & freezer is 2 in height. The refrigerator shelves are 11 in height. Depth of shelves: Depth of shelves in the food compartment is 20 & depth of shelves in the freezer is 20.

Dishwasher controls: N/A Ease of loading/unloading: N/A Ease of transporting items: There is plenty of space in the kitchen which allows for easy transportation of items, including groceries and appliances, the kitchen. Plugs/switches: height, ease of use: All light switches are at a reachable height of 44 from the floor. The switches are also easily accessible and visible. The plugs for appliances in the kitchen are also easily accessible & have a height of 8 from the kitchen counter tops. Storage (ability to reach, handles, organization, amount): Most items in kitchen are stored in a location that are at a reachable distance for the client. The highest storage cabinets in the kitchen are not occupied. Kitchen items are slightly unorganized. Items that are not frequently used are stored in different cabinets. DME typically used in this area: N/A Ways to improve occupational performance, improve mobility, and/or improve safety in kitchen area? The lighting in the kitchen should be improved to safety. One of the light bulbs is out & the lighting is dim. To improve occupational performance items should be organized in the kitchen cabinets based on frequency of use & purpose of items. Bathroom Occupations that take place in the master bath: Showering Grooming Toileting Cleaning Width of doorway: 36 Flooring: Tile Types of faucets at sink: metal, disk type of faucet Types of faucets in tub/shower: round knob Non-skid surface in tub/shower: N/A Height of step into tub/shower: 16 Height of toilet: Floorseat: 16 Type of lever to flush: basic plastic trip lever

Location of toilet paper: on wall next to toilet seat Plugs/switches: 1 Height of mirror: 36 Cupboards (height, type of handle, organization): The cupboards are 24 in height, are located below the sink, & they open by using the thick edge of each door. Items are organized below the sink the exception of a toothbrush, toothpaste, & soap above the sink. DME typically used in this area: N/A Ways to improve occupational performance, improve mobility, and/or improve safety in bath area? Installing a shower chair will improve the clients occupational performance in the shower, because she has back problems that limit her standing endurance. A grip mat in the shower will also help prevent falls. Storing commonly used items on top of the sink, instead of in the cupboards under the sink will help the client conserve energy & eliminate the need of bending down to retrieve/return items. Bedroom Occupations that take place in the bedroom area: Sleep/rest Dressing Watching television Reading Doorway width: 29 Type of door/knob to access closet: sliding door; no door knob Height of closet rod: 65 Type of handles, ease of use of Dresser drawers: brass drawer pull handles, dresser drawers are easy to open & close, handles allow for an easy grip Organization of storage/ease of finding items? Organization of storage of items is poor, items scattered on the floor & pill bottles piled in different locations / ease of finding items is limited due to organization & limited storage space Height and type of Lighting: 1 desk lamp, 29 Ease of access to lighting by the bed: lamp is located near foot rest of bed; can be easily accessed entering the room, but not from the bed DME typically used in this area: N/A

Ways to improve occupational performance, improve mobility, and/or improve safety in bedroom area? the lighting in this room would significantly improve occupational performance, mobility, & safety. It will allow the client to easily search for items, read, & see what is in her path so that she does not trip or fall. Adding shelves or another cabinet will allow the client to organize scattered items on the floor, conserve energy, & safety. Living room Occupations that take place in the living room: Social participation Watching television Talking on the phone Doorway width: 36 Most used furniture (type and height): o o o 2 sofas, 36 Wooden Coffee table, 14 Television stand, 22

Locations and Ease of access to electronics: o o o Television is located in front of the living room, across from sofas, & can be easily accessed. Telephone is located near sofas on the coffee table. Can be easily accessed while sitting on sofa or by walking to it from any point in the living room. Remote controls are also located on the coffee table near the sofas & can be easily accessed.

Types and controls of window coverings: horizontal blinds, controlled by pulling on string Types of controls to open/close windows: windows open & close manually by flipping a plastic lock & sliding the window to the side Storage (type, access, organization): Items in living room are accessible, organized, & stored on the coffee table & television stand. Items are easily visible & there is limited clutter. DME typically used in this area: N/A

Ways to improve occupational performance, improve mobility, and/or improve ease of use in living room area? To improve occupational performance & ease of use, I would recommend spacing the sofas slightly more apart. This will allow for people to walk pass comfortably if there are individuals sitting on the sofas. Cleaning: Laundry (front/side load, controls, storage of detergent): Laundry is front load, controls are regulated by a dial, & storage is located above the washer on a shelf. Client can easily reach detergent & items on shelf. Supplies (able to reach, organization, location): Cleaning supplies are located on the first floor under the kitchen sink. Client must bend down to reach necessary items. Cleaning items organized in different cupboards in the kitchen. Garbage removal (bags, process, transport): Garbage bags are carried outside to the trashcan & then the trashcan is pulled out to the curb. Equipment (vacuum, mop, broom, dustpan): Client owns mop, broom, & dustpan. All equipment mentioned is stored in a closet next to the garage. Client must go & stairs to retrieve items when cleaning the whole house. Ways to improve occupational performance, improve mobility, and/or improve ease of use related to cleaning? To conserve energy & improve ease of use, client can store cleaning items commonly used (e.g. window cleaner, disinfectant spray, bleach) both downstairs & upstairs. In other words buy two of each so that she does not have to go stairs to retrieve the cleaning items. Also, organizing all of the cleaning materials in one cupboard, instead of different cupboards, will eliminate the need of searching for items. Additionally, instead of carrying a heavy garbage bag from the kitchen to the trash can outside, client can buy a rolling trashcan that will allow her to pull the trash outside or only fill up half a trash bag. Other considerations Ease of access to communication within and throughout the home: There is only one land-line telephone in the living room, which the client can access easily on the first floor. Client also has easy access to her cell phone. Client must go or stairs to communicate other individuals in the home. Access and ease of use of Thermostat: Thermostat located above the light switch in kitchen. Access to the thermostat is difficult for the client, due to the clients short stature. Thermostat controls are easy to use & follow. Access to Community Transportation: Client has easy access to community transportation from home. Bus stops located around the corner & client drives own car.

Access to grocery Store, drug store, etc.: Grocery stores, drug stores, & other convenient stores are located near the clients home. Client has easy access to these stores & drives to them almost daily. Pets in the home and any related safety concerns: No pets in home Presence of environmental hazards (rugs, cords, obstacles in major pathways, etc.): Throughout the home there are pieces of rug that function as rubber mats. They are placed in front of the doorway entrances, hallways, & stairs. These pieces of rug sometimes get caught in the doors & require someone to manually pull them from beneath the door. They also easily shift & move when someone walks on them, which is a safety concern. No other major obstacles or cords noted in major pathways. Summary: List the top 5 modifications to the space that you feel would have the biggest impact on improving occupational performance, mobility, and/or safety in the home. 1. Removal of the pieces of rug around the house & replacing them plastic or rubber non-skid mats to safety during amb 2. Replace light bulbs & add other light sources (e.g. lamps) to the lighting in the house, including the bedroom, kitchen, & living room 3. Adding cabinets or shelves to the clients bedroom to allow the client to organize, store items at a reachable height, & remove clutter from the floor. 4. Place commonly used items in the kitchen & bathroom on the counters to prevent bending & to conserve energy 5. Removal of the gravel & large rocks from the walking pathway in the back entrance to improve mobility & safety Additional recommendations: Lower items that are hard to reach (e.g. thermostat) Buy duplicates of cleaning supplies to maintain one of each product upstairs & downstairs to conserve energy during cleaning Install shower chair & non-slip bathroom mat Avoid using pots insulated handles

Occupational Therapist Name Printed: _Kelly Garcia_______________________________________ Signature: _

Kelly Garcia______________________________________________