Home environment evaluation recommendations Form (1)

Home Environmental Assessment and Recommendations Table

First, the basic data

Case Name: Gender: Date of birth: Years Month 2011 Age:

Handicap category: Disabled Manual Font Size: Level:

Location:

Diagnosis: Contact: Date:

Contact Person: Relationship: Phone:

Itself Occupation: Father Occupation: Mother Occupation: Low-income households: □ Yes □ No

Diagnosis:

After returning home to play the roles of: □ Student □ □ Homemaker volunteer worker □ □ Other

Human Petty Information: (Please fill the need at)

Height: cm, sitting height: cm, weight: kg, hip width: cm,

Nest hip knee length: cm, knee high: cm, Shoulder: cm, knee high nest: cm

Sitting

Eye Height: cm, shoulder height: cm, elbow height: cm, waist high: cm,

Hand and (upwards): cm, hand and (DOWN): cm, hand and (forward): cm

Standing

Eye Height: cm, shoulder height: cm, waist high: cm,

Hand and (upwards): cm, hand and (DOWN): cm, hand and (forward): cm

Major mobile aids:

1. □ No 2. □ single cane 3. □ two canes 4. □ legs Abduction

5. □ four-legged walker 6. □ underarm turn 7. □ manual wheelchair 8. □ electric wheelchair

9. □ Other

長 Wheelchair / sub-deck appliances Specifications: Length cm in width cm high cm

Housing Ownership:

1. □ from home 2. □ Renting 3. □ relatives or children of the house 4. □ Other _____________

Dwelling types: 1. □ F 2. □ above the second floor without elevator, Floor, stairs Rank

3. □ above the second floor with elevator, Floor

4. □ Other

House situations:

Number of indoor floor room ___________ ________ Layer floor house floor

House stairs ___________ order House elevator: □ No □ Yes

Inmate number (including their own): 1. □ 1-2 2. □ 3-4 3. □ 5-6 4. □ 7 +

Outside traffic conditions: 1. □ Mild busy 2. □ moderately busy 3. □ Severe busy

居家環境平面圖 並標示個案之 主要動線 ： Please draw the home environment with floor plan and mark the major cases of moving lines:

Due to the environment or cause danger affecting the implementation of project activities

Environmental modification or aids required items

Require modification or use of the environment

Reasons aids

) Environmental Modification or use of assistive devices recommended (name, size, construction methods)

, Detailed recommendations can choose Schedule

停車位 □ Parking

Inlet channel

升降設備 □ lifting equipment

斜坡 □ slopes

樓梯 □ Stairs

出入口 □ entrances

Indoor Environment

客廳及餐廳 □ living and dining

走廊通道 □ corridors

臥室 □ bedroom

浴室 □ bathroom

書房/工作室 □ Study / studio

廚房 □ Kitchen

其他 □ Other

Comprehensive advice: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________