Self-Guided Home Accessibility & Safety Review

Resident Name

Caretaker/Representative Name (or self)

Relationship to Resident (or self)

Address

City, State

Zip

Preferred Method of Communication

Call

Text

Best Times to Reach You

Your Goals

Who is this review primarily for?

Myself

Spouse

Parent

Family Member

Client/Patient

Other

What prompted you to request an assessment at this time?

What would you most like to improve about your home?

Everyday Movement & Balance

Consider how you enter and exit your home.

Are there steps required to get in or out?

Yes

Do those steps feel safe and manageable?

Yes

Are handrails secure and comfortable to use?

Yes

Sometimes

Would easier access (such as a ramp or improved handrails) make entering and exiting feel safer?

Yes

Not Sure

Is the entry area well-lit in the evening?

Yes

Not Sure

Bathroom Comfort & Safety

The bathroom is one of the most common places for falls. Reflect on how it feels to use this space.

Do you feel completely safe stepping out of your shower or tub?

Yes

Not Sure

Do you need to hold onto something while exiting or entering?

Yes

Are grab bars installed where you would normally reach for support?

Yes

Do you feel stable while standing in the shower?

Yes

Not Sure

Would a walk-in or barrier-free shower improve your comfort or safety?

Yes

Is the toilet easy to sit down on and stand up from?

Yes

Sometimes

Bathroom Concerns or Wishes:

Stairs & Interior Movement

If your home has stairs:

Do you feel safe and confident using them?

Yes

Sometimes

Would you prefer to limit or avoid stairs if possible?

Yes

Do stairs feel tiring or difficult?

Yes

Would a stair lift improve your confidence or safety?

Yes

Not Sure

Notes about stairs:

Doorways & Room Transitions

Yes

Are there doorways that feel narrow or difficult to pass through?

Yes

Would a walker or wheelchair comfortably fit through all doorways?

Yes

Are there thresholds or transitions between rooms that create a trip hazard?

Yes

Additional Concerns:

Daily Living & Independence

Are there everyday activities that feel more physically demanding than they used to?

Yes

Are there areas of your home you avoid because they feel difficult or unsafe?

Yes

Would thoughtful modification help you to remain independent longer?

Yes

Not Sure

Please share any additional thoughts:

Looking Ahead

Are you planning to remain in this home long-term?

Yes

Not Sure

Are you planning improvements to prepare for future mobility needs?

Yes

Are you interested in professional recommendations tailored to your home?

Yes

Anything Else?

Is there anything important about your home, health, or goals that we should understand before coming to your home?

Thank you for completing this review. Your thoughtful responses help us understand your needs and prepare practical, personalized recommendations for improving safety and comfort in your home.

🚧 Welcome to Healthy Home Improvements 🚧

🚧 Welcome to Healthy Home Improvements 🚧

🚧 Welcome to Healthy Home Improvements 🚧