Home for Life Design

Home Assessment Report

Jennifer Tom of Touro University, performed the following occupational therapy home assessment to determine the safety
and current functional status of Otty in the home. This report details Robyn Ottys feeling of safety and measures the
accessibility of important occupations that occur throughout areas of the home. Information was gathered via
professional interview with the client and/or family, activity analysis, objective measurements and photography. This
assessment was performed on: 9/30/2015

Patient Information:
Patient Name:

Otty, Robyn

Date of Birth: 1/9/1970

Address:

2869 Matese Dr.

Gender:

Female

Henderson, NV 89052
Tennant Type:

Owner

Is Veteran:

No

Housing Type:

Single Family

Has HOA:

No

No. Floors:

Lives With:

SpouseChild

Special Considerations:
Inaccessible Areas were accessible
Areas:
If the client has fallen, did the most recent fall:

Assistive Grab bars present in the shower and toilet

Devices:
Where did the fall occur: N/A

Result in Injury: No

What Room:

Result in Hospitalization: No

Fall Cause Type: N/A

Result in Rehabilitation: No

Fall Cause Comments: Client has no history of falls

Other Considerations:
Consideration Type

Therapist Note

Home and Personal Findings:

The following rooms assessed each indicate the Personal Safety Rating given by the patient and the Therapist
Accessibility Rating determined by activity analysis during skill performance:

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Pre-Assessment
Personal Safety
Rating %

Therapist
Accessibility
Rating %

Bathroom, In masters bedroom

100.00 %

100.00 %

Bedroom, Master bedroom

100.00 %

90.00 %

Dining Space, Next to the kitchen

100.00 %

100.00 %

Entryway, Front of the house

100.00 %

100.00 %

Kitchen, Left corner of the house

100.00 %

92.86 %

Living/Family Room, Right side of home

50.00 %

100.00 %

Hallway,

100.00 %

100.00 %

Outdoor Space, Backyard

100.00 %

100.00 %

0.00 %

0.00 %

Room Assessed

Stairs, N/A

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Post-Assessment
Therapist
Personal Safety
Accessibility
Rating %
Rating %

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Home Recommendations Based on Findings:

Bathroom, In masters bedroom

Personal Safety Rating

Accessibility Rating

100.00 %

100.00 %

Recommended Modifications:
- Rug w/ Anti Slip Backing

Bedroom, Master bedroom

Personal Safety Rating

Accessibility Rating

100.00 %

90.00 %

Recommended Modifications:
- Organize/Declutter Space
- Create Accessible Closet

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Dining Space, Next to the kitchen

Personal Safety Rating

Accessibility Rating

100.00 %

100.00 %

Recommended Modifications:

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Entryway, Front of the house

Personal Safety Rating

Accessibility Rating

100.00 %

100.00 %

Recommended Modifications:

Kitchen, Left corner of the house

Personal Safety Rating

Accessibility Rating

100.00 %

92.86 %

Recommended Modifications:

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Living/Family Room, Right side of home

Personal Safety Rating

Accessibility Rating

50.00 %

100.00 %

Recommended Modifications:
- Add Lighting

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Hallway,

Personal Safety Rating

Accessibility Rating

100.00 %

100.00 %

Recommended Modifications:

Outdoor Space, Backyard

Personal Safety Rating

Accessibility Rating

100.00 %

100.00 %

Recommended Modifications:

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Stairs, N/A

Personal Safety Rating

Accessibility Rating

0.00 %

0.00 %

Recommended Modifications:

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Additional Service Recommendations (e.g. home health, medication management):

Additional Notes:
Client has a bathroom mat outside the shower doors. It is recommended to implement non-skid shower mats to prevent
falls.

Submitted By:

Jennifer Tom, , License #

10/1/2015

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