Innovative Building and Remodeling Solutions
for Independent Living

The first step to continuing to live independently is an assessment.

We look forward to eventually meeting with you in person to fully evaluate your modification needs and options. The following assessment questionnaire is a good starting point. This tool will begin to measure the condition of your home as it relates to your abilities and planning to Age-in-Place.

The following questions are not meant to be all-inclusive. Rather, this questionnaire is designed to be a thought-provoking introduction that will help you understand your environment and how it can be improved to better fit your lifestyle and abilities.

If you’re planning to Age-in-Place, this is the beginning of a journey that will help you maintain your quality of life and independence. Many of these questions relate to safety and can be used to make any home safer.

Remember, this questionnaire is not meant to replace the professional assessment normally completed by a physical therapist, accessibly specialist or a Certified Aging-in-Place Specialist (CAPS).

Home Evolutions would like to complete our own professional assessment after meeting you in person and visiting your home.

Before answering the following questions, please take a moment and think about how you (or your family member) complete some of these tasks each day.

Tell Us About Yourself

We would appreciate hearing a little about you and your home.

Require fields are marked with an asterisk (*).

*First Name:

*Last Name:

Address One:

Address Two:

City:

State:

Zip:

Phone:

*Email Address:

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How long have you lived in your current home?
5 years or less
6-10 years
11-15 years
16-20 years
21 years or more

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How many people are currently living in your home?

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In what age group(s) are the residents? (Please check all that apply)
Under the age of 25
25-34
35-49
50-59
60-74
75-84
85 or older

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In general, would you say your health is: Excellent
Very good
Good
Fair
Poor

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Do you have any disabilities? If so, are your disabilities temporary, permanent, progressive?

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Are you having difficulty in any of these areas? (Please check all that apply) Getting in and out of the home
Using the stairs
Moving from one room to another
Using the kitchen
Preparing meals
Using the bathtub or shower
Using the toilet
Getting in and out of bed, chairs, sofas
Doing laundry
Opening, closing or locking windows and doors
Operating light switches or faucets

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Do you have problems moving around in any areas of your home? If so, which rooms? (Please describe in detail what problems you are having.)

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Are you currently receiving any support/community services (transportation; dressing; bathing; housework; shopping; meals; other)?

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What do you want to learn from a one-on-one professional assessment with us?

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What brought you to our Web site?

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Is there any other information about yourself that you would like us to know?

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