Your Name (required)

Your Email (required)

Is there a step-free entrance to your home?
 Yes No

Do you have doorbell intercoms?
 Yes No

Does your main door have a covering to keep you and your visitors dry?
 Yes No

Is there adequate lighting at your main entrance to aid in seeing the lock and in seeing visitors who might come to your home?
 Yes No

Are any of your floors possible slip hazards?
 Yes No

Do you have a bedroom, full bathroom, and kitchen on the main floor?
 Yes No

Are these critical rooms "barrier free"?
 Yes No

Is your laundry area on the main floor?
 Yes No

Are your washer and dryer front-loading machines?
 Yes No

Would a wheelchair be able to pass through your halls and doorways?
 Yes No Not Sure

Do you have lever handles on all your doors and faucets?
 Yes No

Does your current kitchen design have countertops of varying heights to accommodate both standing and sitting positions?
 Yes No

Has your dishwsher been raised up to make it easier to access?
 Yes No

Do your appliances (especially your stove) have front-mounted controls for easy reach?
 Yes No

Can you easily reach your kitchen and bath cabinets?
 Yes No

Is the lighting adequate in your hallways and stairwells?
 Yes No

Is it sometimes uncomfortable to turn on/off your light switches?
 Yes No

Do your stairwells have handrails on BOTH sides?
 Yes No

Do your carpeted rooms cause you to trip occasionally?
 Yes No

Does the height of your bed cause problems getting in or out?
 Yes No

Do you occasionally have trouble seeing because of lack of light or because of adjacent color contrast?
 Yes No

Do you occasionally have difficulty gripping things such as cabinet drawer knobs?
 Yes No

Do your cabinets have full-extension pull-outs for easy access?
 Yes No

Do you have comfort-height toilets (17"-19" off the floor) in your main bath?
 Yes No

Do you have conveniently located grab bars of sufficient sturdiness?
 Yes No

Does your shower have a hand-held shower head?
 Yes No

Is there an adequate non-slip surface in your bathtub(s) and/or shower(s)?
 Yes No Not Sure

Do you have a curbless shower that would grant easy access to someone in a wheelchair?
 Yes No

Additional Comments