Occupational Therapy Home Assessment form.


  1. Client’s Health and Medical Condition.

O is a 14 year old girl with a diagnosis of quadriplegic spastic cerebral palsy (GMFCS

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Level 5 and MAC level 5).

Current medications:- epilim, gabapentin, lamotrigine, kepra, zoton, glycopyrrolate,

baclafin, artan, bactrim and medazlon.



Days of work:-

Registration Number:-

Medicare Provider Number



  1. Social Situation.

  Client Name:

  Date 10 May 2016

O resides with her two older sisters, and her mother (K) and father (G). Her

grandparents reside in an adjoining property. Residence built in 2004-5 with design

taking into consideration O needs at that time.

  1. Client’s Functional Status.

O mobilises with an attendant care manual wheelchair. She is dependent on her carers

for all activities of living(ADL) and instrumental activities of living (IADL).In receipt of

morning and afternoon personal care, and in home respite.

O is fed via a gastrostomy, and she requires suctioning to manage her secretions during

the day. K reported that O silently aspirates during the night and requires additionally

suctioning during this time.

  1. Equipment Used.

Item Comment

Manual wheelchair Mother advised that electric wheelchair

will be scripted in the future.

Hi Lo hospital bed with pressure encased


Clear path of travel and circulation space

will require consideration in home

modification design.

O is tall for her age, and current bed is not

suitable for her anthropometrics, and her

orthopaedic requirements (O has rods in

her back).

O will require a king single hi lo bed to



Days of work:-

Registration Number:-

Medicare Provider Number


accommodate her height.

  Client Name:

  Date 10 May 2016

Wall mounted fold down shower tray wall

in  hobfree step down shower recess

Showertray is still appropriate for use.

Ceiling tracking hoist in bedroom 2. Current tracking hoist does not work.

Limited circulation space surrounding bed

and potential for manual handling risks for


Continence pads

Sonata heavy duty electric hoist and sling The hoist allows for movement from bed to

chair and bathroom, however it is limited

in existing the bedroom door and turning

90ᶿ to access hallway to bathroom and

then 90ᶿ to enter bathroom area.

  1. Home Environment.

Single storey brick residence on concrete slab.

Access:-  Front The home is accessed from the road via a gravel drive, joining to a

paved pathway. There is a garage on the left on facing. . This is not the preferred

entrance.  Height of step into house 160mm, limited space due to front pillars at





Days of work:-

Registration Number:-

Medicare Provider Number




  Client Name:

  Date 10 May 2016

Whilst this access can be modified it is not the preferred access due to

 Front door would require widening to accommodate a wheelchair

 Path of travel is narrow and would require carer to undertake 90ᶿ turn. This

presents a manual handling risk to navigate to main family living area and


 O would be exposed to the elements of an uncovered ramp which are

detrimental to her health, and the side ramped entrance is under cover.

Side access:-

This is the preferred access. Currently accessed via drive through garage. The rear

yard is covered, which prevents Olivia being exposed to the elements when


The existing brushed concrete ramp does not comply to the National Construction

Code (NCC) and Building Codes (BCA)(2016) being 270mm in height and 2220mm in

length, thus providing approximately  1:8 gradient on a ramp that should be 1:14

(NCC/BCA 2016 and in consideration of AS 1428.1 (Design for Access and Mobility.

Part 1(2009, Incorporating Amendment No 1): General requirements for access- New

Building work) .




Days of work:-

Registration Number:-

Medicare Provider Number…………………………………….




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