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Health Profile
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Functional Deficits |
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Poor Grip Lacks Coordination Upper Limbs (U.L.) Lower Limbs (L.L.) |
Poor Tolerance Muscles Weakness Poor Balance Reduced Mobility Cane/Walker Wheelchair Dependant Ventilator Dependant |
Sensory Loss Low/No Vision Hearing Loss Tactile Loss Impaired Speech Non Avg Height Obese |
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Limited Reach
(U.L.) (L.L.) Trunk |
Mental Status
Alert Confused Disoriented Time Space |
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Characteristics of the Residence/Workplace
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| Type of Tenure: Owner Renter | ||
| Type of Dwelling/Unit/Building: |
Condition of Building:
Poor Average Good |
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Single Family Semi-Detached Row/Town House Plex (# of units) Building less than 5 Stories Building more than 5 Stories Other |
Level:
Basement 1st Floor 2nd Floor 3rd Floor |
Room:
Bathroom Kitchen Bedroom Closet Entrance Staircase |
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Description of Access Problem:
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Possible Solutions:
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Assessment / Report Required
Physical/Cognitive Assessment Site Analysis Home/Workplace Safety Report Future Plan Report Project Outline
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Copyright © 1996, EASY ACCESS. ALL rights reserved Last update - 30/12/96 - JBH |