Adapted with permission from Louisiana State University Health Sciences: Department of Occupational Therapy
CLIENT INFORMATION- CONFIDENTIAL
OCCUPATIONAL THERAPY
HOME MODIFICATION REPORT
Name:
Address:
Contact Phone Number:
File Number:
Date of Birth/Age:
Date of OT Visit:
Present at Visit
Client:
Occupational Therapist (name of organization and phone #):
Client Profile:
1. Health Condition or Disability Specific Information
Client reported he/she has the following medical condition, which affects his/her daily function:
o State source of information-for example, client/medical reports/family stated.
o List medical conditions/disability in point form.
o Be concise
o Avoid jargon
o Describe unfamiliar conditions in simple language.
2. Level of Mobility
o Brief paragraph including the following:
o Primary method of mobility
o Walking and standing tolerances
o Balance ability
o Transfer ability/technique-on/off bed, chair, toilet; in/out bath, shower
o Ability to use stairs and how many
o Ability to manage ramps and hills
o Community access-public transport options used, private vehicle use
CLIENT NAME:
1
Adapted with permission from Louisiana State University Health Sciences: Department of Occupational Therapy
CLIENT INFORMATION- CONFIDENTIAL
3. Level of Independence
Brief paragraph including the following:
o
o
Independence with activities of daily living: personal and domestic
Information related to person (not to do with housing needs)-for example, care assists client in
shower because she is unable to safely transfer in/out of shower or turn taps on/off
Use of Equipment
o
o
o
Currently used equipment
Future needs and clarification of how future needs were determined
Measurements for wheelchairs, hoists, etc., to be included
4. Wheelchair
o Length (occupied or unoccupied)
o Width (occupied or unoccupied)
o Floor to top of toe with foot on footplate
o Floor to top of knee with foot on footplate
o Floor to armrest
o Floor to hand on top of hand control on armrest
o Turning circle
o Diagram of wheelchair dimensions to be attached if required
5. Hoist
o Width
o Length
o Height of feet above floor level
o Turning circle
CLIENT NAME:
2
Adapted with permission from Louisiana State University Health Sciences: Department of Occupational Therapy
CLIENT INFORMATION- CONFIDENTIAL
Anthropometric Measurements of Client
1. Support Services
o Type of support services being used
o Frequency of service
o Include informal and family support
2. Brief Description of Property:
o Include details of present housing situation
This next section is to give the reader an understanding of the house layout and the problems the client is
experiencing or likely to experience in the future so that he or she is able to understand the need for the
modification and/or suitability of the property. The home audit checklist gives a guide for items to be
included in each section but not all points will be necessary. Some areas may say, "No problems reported,”
but more detail is required if it relates to the client's request for modification.
If a problem is identified or is anticipated due to the nature of the disability/medical condition, the report
should indicate how the client is coping with the problem. For example, if it is noted that the client has
difficulty coping with stairs and the current accommodation has five steps, the report should indicate how
the client is coping with the stairs or if a modification is required.
1. External Access
o Site of accommodation-for example, sloping block, busy road
o Paths/driveways
o Stairs-how many and if there are handrails
o Security screens-any the department has installed
o Access to mailbox, trash cans, and clothesline
Is the client experiencing problems with any of these areas or, because of the nature of the client's
disability, does the occupational therapist expect that he or she would be experiencing difficulties?
2. Internal Access
o Floor levels
o Corridor and door widths
Is the client experiencing problems in this area?
3. Bathroom/Toilet
o Type of facility-for example, shower over bath, square bath, separate shower and bath facilities
o ls the toilet combined in the bathroom or in a room adjacent (future modification possible)?
CLIENT NAME:
3
Adapted with permission from Louisiana State University Health Sciences: Department of Occupational Therapy
CLIENT INFORMATION- CONFIDENTIAL
o
o
o
Height of hob or bath
Type of flooring
Existing modifications
Is the client experiencing any problems with any of these areas?
4. Kitchen
o General layout, for example, large kitchen used for dining as well as meal preparation
o Type of stove-for example, upright electric
Is the client experiencing any problems with any of these areas?
5. Laundry
o Location of laundry and if there are paths to clothesline
6. Is the client experiencing any problems with any of these areas?
7. List any other issues arising.
Recommendations:
Complete the following table to set out how problems identified in the housing situation section are to be
solved and linked with the original request. Justify all modifications and show that the least expensive
and easily achieved modifications have been considered before a modification has been requested-for
example, before recommending a bath be removed, note that a bath board was trialed or not suitable for
a stated reason.
CLIENT NAME:
4
Adapted with permission from Louisiana State University Health Sciences: Department of Occupational Therapy
CLIENT INFORMATION- CONFIDENTIAL
RECOMMENDATIONS
REASONING/OTHER OPTIONS CONSIDERED
The client was in agreement with the recommendations listed above at the time of the interview.
Signed:
Approved by:
______________________________
Occupational Therapist
______________________________
Program Manager
Date: _________________
Date: _________________
CLIENT NAME:
5
Adapted with permission from Louisiana State University Health Sciences: Department of Occupational Therapy
CLIENT INFORMATION- CONFIDENTIAL
HOME MODIFICATIONS BRIEF TO CONTRACTOR
Name:
Address:
Contact Phone Number:
File Number:
MODIFICATIONS:
Note:
1. Modifications are based on specific client requirements. Any alteration to this brief should be checked
with the Occupational Therapist,________________________ , phone:___________________
2. Drawings (where provided) are not to scale and should be read in conjunction with the written brief.
3. Paint/repair all areas disturbed.
Signed:
Approved by:
________________________________
________________________________
Occupational Therapist
Program Manager
Date:
Date:
CLIENT NAME:
6