HOME ACCESSIBILITY

QUESTIONNAIRE
 Spaulding Rehabilitation Hospital
Home Accessibility Questionnaire

Patient name Room #

Please return to: Phone:

What type of services did the patient have prior to hospitalization? (i.e. home health aide,
homemaker, PT, OT, Speech?)

What type of equipment did the patient have prior to admission (i.e. walker, wheelchair, cane,
commode, tub seat, etc.)

Form completed by: Phone:

Date:

Type of Dwelling:
Home

How many levels/floors of living space does your home have?

1 2 3 Other

If more than one floor, is there a bedroom on the first floor?

Yes No (circle)

If more than one floor, is there a bathroom on the first floor?

Yes No (circle)

1.
Apartment

On what floor is your apartment?

If there are stairs to enter, how many Is there a railing? Yes No

Is there an elevator? Yes No (circle)

Is your apartment handicap accessible? Yes No (circle)

Entrance
Which entrance is used most frequently?

Front Back Side (circle)

What type of surface leads to the above entrance?

Grass Cement Gravel Other

Is there a porch at or leading to the entrance?

Yes No (circle)

What entrance is the most “accessible” (i.e. least amount of stairs, railing available, etc.)

Stairs

How many steps are there to enter?

What is the height and depth (in inches) of each step?

Height: Depth:

Is the railing (as you go up the stairs) present on:

Right Left Both (circle)

2.
Landing

Does the landing have a railing? Yes No (circle)

If yes, on which side is the railing as you face the entrance?

Left Right Both (circle)

Is the landing large or narrow with little room to maneuver or turn?

Width of the landing:

Entrance Doorway

What is the width of the doorway in inches?

(*measure from edge of door to opposite molding for the narrowest width)

Does it swing in or out?

Is there a screen or storm door in addition to the main door?

Interior of Home/Apartment
Hallway

Width of main hallway?

Is hallway straight or L-shaped?

Circle rooms off the main hallway:

Bathroom Bedroom(s) Kitchen Dining Room Living Room Family Room

In what room do you sit most frequently?

Width of doorway in inches?

In what type of chair do you sit most frequently?

3.
Type of floor surface in this room?

Bedroom

Width of doorway in inches:

(*measure from edge of door to opposite molding for the narrowest width)

Is there a threshold? Yes No (circle)

Type of bed: Twin Double Queen King Hospital (circle)

Height of bed (from floor to top of mattress) in inches:

Are both sides of the bed approachable? Yes No (circle)

Approximate distance to bathroom:

Kitchen

Width of doorway in inches: 

(*measure from edge of door to opposite molding for the narrowest width)

Is there a threshold? Yes No (circle)

What is the shape of the kitchen? U-shaped Gallery Other

Distance from the meal preparation area to table:

What types of chairs are at the table? Armchair No arms Wheeled Stool

4.
 PLEASE SKETCH A DIAGRAM OF THE KITCHEN. BE SURE TO INCLUDE
REFRIGERATOR, STOVE, SINK AND TABLE IN THEIR APPROXIMATE LOCATIONS.

Bathroom

Width of doorway in inches:

(*measure from edge of door to opposite molding for the narrowest width)

Is there a threshold? Yes No (circle)

Does the door swing in or out?

Type of floor covering? Carpet Wood Tile

Toilet

Height from floor to top of seat (lift lid):

Depth of toilet seat: Width

Are there grab bars beside the toilet? Yes No (circle)

If yes, which side?

5.
If sink is next to the toilet, what is the distance between them?

Sink

Height of sink:

Does sink have an open bottom or cabinet below?

Does patient use: Tub/shower Showerstall Sponge bath (circle one)

Tub

Height of tub from floor to rim:

Standard tub or Old-fashioned (higher rim) (circle one)

Shower doors or Shower curtain (circle one)

If doors, width of opening:

Can doors be removed?

Are there safety or grab bars in the bath tub?

location:

As you face the tub, which side are the faucets/ showerhead located? Left Right

Showerstall

What is the doorway width?

Is there a Door or Curtain? (circle)

If door, which way does it swing out? Right Left

Height of lip to enter showerstall?

6.
 PLEASE SKETCH A DIAGRAM OF THE BATHROOM. BE SURE TO INCLUDE TOILET,
TUB, SINK, AND DOORWAY IN THEIR APPROXIMATE LOCATION.

Therapist Recommendations:

Signatures:

OT:

PT:

7.
 ADA Recommendations
Walkways and Ramps
• Gently sloped—maximum recommended ramp slope is 8%
• Have a non-slip surface
• Handrail should be provided on at least one side and should extend beyond the top
and bottom
• Minimum width of ramp 36”
• Should have a 5 foot level surface at the top and bottom for ramps longer then 30’
• 1 foot of ramp for every inch of step (ex: 4’8” stairs require a 56 ft. ramp)
• 5’ x 5’ area must be provided if ramp needs to turn

Entrances/Exits
• Minimum of 32 inch clear opening
• Easy to push or pull open
• Thresholds should be no higher than ½”

Corridors/ Hallways
• Minimum of 48” free of obstacles

Bathrooms
• Height countertop/ sink vanity for wheelchair is 28” - 34.” Knee space of 6 1/2”
depth with insulated pipes is recommended under the sink.
• Toilet-recommend height to be approximate height of wheelchair. Toilet seats
higher than 18 1/2” preclude commode use. 3” space between toilet and an
adjacent wall is recommended for grab rail use.
• ADA roll in showers must provide an inside shower dimension of 60” x 30.”
The controls and spray unit on the back (long) wall shall be located a maximum of 27
inches from the side wall where the seat is attached.
• Bath tub / shower- recommend placement of shower curtain and removal of
glass doors. Must have adequate space to accommodate the width of the wheelchair
along side the tub ~28” in width. Hand held shower head and easy to operate shower
controls-single level controls are recommended.

8.
Kitchen

The recommended countertop height is a minimum of 28” and should be no higher than 34”
(32” is preferred). Space for knees requires at least a 24” height from the floor and approxi-
mately 30” in width.

A wheelchair accessible sink should be shallow, only 5” to 6 1/2” deep, which allows the cook
to sit or stand while working. The faucet should be a loop or single lever for easy operation.

Locate the sink’s drain at the rear to keep the knee space clear. Insulate the hot water pipes in
the open area under the sink to prevent burns.

Lowering the wall cabinets from the standard 18 inches above the counter to 15 inches will
make the second shelf accessible for everyday use for most people.

Mount or lower wall cabinets closer to the countertop and include pull-out cutting boards,
slide-out or roll-out shelves and baskets, and drawers with full extension glides.

For a wheelchair user, you want to lower or install a wall oven and microwave so they are
approximately 31” from the floor. Install an electric cook top unit with to eliminate reaching
across hot burners.

For a range, look for a slanted control panel with recessed control knobs that are easy to hold
and to turn. Front positioning of knobs and control panel signal lights will make the range
easier and safer for those in wheelchairs. If possible, make the oven accessible from either side
or search for an oven with a side-hinged door.

Raise the dishwasher 6” to 8” off the floor and locate the unit so it is accessible from either
side.

9.
NOTES

10.
Spaulding Rehabilitation Network
300 First Avenue
Charlestown, MA 02129
617.952.5000
www.spauldingrehab.org