Home Assessment Form

Suppliers of wheelchairs, scooters and similar equipment check whether a patient's home can actually take them. Housing type, accessibility, manoeuvring space and the results of equipment trials are all documented. The supplier signs off the conclusion so the delivery matches the living space.

Use this template

Section

Name

Nombre

Apellido

Date of Birth

Phone Number

Email

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Please Select Type of Mobility Assistive Equipment (MAE)

Please Select Type of Home

Single-family house Apartment Mobile home Assisted living residence Condominium

Handicap Accessible?

Yes, fully Partially No

Equipment Trials

Nombre

Apellido

Section

Are there any factors such as temperature, physical layout, surfaces, or obstacles that will render the product unusable in the beneficiary's home?

Yes No Cannot be determined

Please give details

I, the supplier, have completed an assessment of the patient's home and conclude based upon this information the patient's home will accommodate the following MAE(s)

Manual wheelchair Power wheelchair POV or scooter Walker None of the above

Home Assessment Date

Supplier Signature

Sign here

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