Home Assessment Form
Patient Information
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Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select Type of Mobility Assistive Equipment (MAE)
Manual Chair
POV/Scooter
Power Wheelchair
Other
Please Select Type of Home
Single Story
Multi-Story
Apt. /Condo
Mobile Home
Other
Handicap Accessible?
Yes
No
Equipment Trials
Make
Model
Turning Radius
Home Environment
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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
Please give details
Does the patient’s home provide adequate access between rooms, maneuvering space, and surfaces for theplacement of a POV/Scooter?
Rows
Yes
No
Measurements
Bathroom
1
2
Bedroom
3
4
Kitchen
5
6
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 Chair
POV/Scooter
Power Wheelchair
Home Assessment Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Supplier Signature
Submit
Should be Empty: