Home Environment Assessment – Adults and Older Adults with Visual Impairment

This assessment is carried out by a Vision Rehabilitation Specialist / Teacher of Students with Visual Impairments (TVI) in collaboration with you. The purpose is to gain an understanding of how your visual impairment affects your daily life, including your strengths, the challenges you experience, and what is most important to you. Together, we will identify solutions that can promote greater independence, confidence, participation, and quality of life.

Section 1 – About You, Your Goals and Your Situation

1. What is most important to you in your daily life?Select all that apply. Live as independently as possible Feel safe at home Prepare my own meals Read books, newspapers, or mail Use my smartphone, computer, or tablet Shop independently Go out on my own Participate in social activities Continue working or studying Participate in leisure activities Help care for grandchildren or family Travel more Other

2. What would you like help with through this assessment?

3. Name ^*

4. Year of birth / AgeExample: 1958 / 66 years

5. Telephone number

6. Date of assessment ^*mm/dd/yyyy

7. Eye diagnosis / Eye condition (if known)

8. Is your visual impairment Congenital Acquired Gradually progressive Don’t know

9. How do you experience your vision?Select all that apply. Blurred vision Difficulty seeing at a distance Difficulty seeing up close Difficulty distinguishing contrasts Easily affected by glare Difficulty seeing in dim light Reduced peripheral vision Reduced central vision Double vision Vision varies throughout the day Become tired quickly when using my vision Difficulty with visual orientation Other

10. What do you use your vision for most?Select all that apply. Reading Watching television Smartphone Computer Tablet Cooking Hobbies Work / Studies Other

11. How tired do you become from using your vision? Not tired Slightly tired Quite tired Extremely tired

12. Who do you live with? Alone Partner / Spouse Children Other family members Assisted living residence Other

13. Do you have any pets? Yes No

14. Who helps you in your daily life?Select all that apply. Family Friends Home care services Personal assistance services Personal assistant No one Other

15. How would you rate your ability to manage everyday life?

0 = Very poor510 = Excellent

16. How safe do you feel at home?

0 = Not safe at all510 = Completely safe

17. How satisfied are you with your current solutions and assistive technology?

0 = Not satisfied at all510 = Very satisfied

Section 2 – Home Environment, Lighting and Contrast

18. Type of home Apartment Townhouse Detached house Assisted living residence Other

19. Are there stairs in or leading to your home, and are they marked? Yes, and they are marked Yes, but they are not marked No

20. Where is the lighting inadequate?Select all that apply. Kitchen Bathroom Living room Hallway Bedroom Workspace Stairs Entrance Outdoor areas / Driveway

21. Do you experience glare from windows or lighting? Yes, often Sometimes No

22. Which of the following are difficult to see because of poor contrast?Check all that apply. Door handles Light switches Electrical outlets Stair edges Changes in floor level Faucets and mixer taps Stove and oven controls Kitchen countertop Toilet Glasses, cups and plates Dishes and cutlery Medication packages and labels Clothing and colours Mail and letters Mobile phone / Computer screen

23. Are there other areas in your home that are difficult to navigate?

Section 3 – Labelling at Home

24. Have you labelled or adapted any of the following at home?Check all that apply. Stove Oven Washing machine Microwave Medications Cabinets Drawers Spices and food products Freezer Keys Remote controls Clothing (colour/type) Other labelled items

25. What would you like to label or adapt better at home?

Section 4 – Assistive Technology

Optical Devices Hand magnifier Stand magnifier Monocular / Telescope Filter glasses Prism glasses

Electronic Devices CCTV / Video magnifier Electronic magnifier OCR reader Refreshable Braille display

Digital Accessibility Software VoiceOver (Apple) TalkBack (Android) ZoomText SuperNova JAWS NVDA Windows Narrator Zoom (iOS/macOS)

Daily Living Aids (ADL) Talking clock Talking scale Colour identifier Light detector Liquid level indicator White cane Guide dog Braille

26. Do you use your assistive technology regularly? Yes, every day Sometimes Rarely Never

27. Have you received sufficient training in using your assistive technology? Yes Partly No

28. Do you need new or improved assistive technology?

Section 5 – Cooking

29. Do you experience difficulties with…Check all that apply. Reading recipes Finding the correct ingredient Determining whether food is fully cooked Using the stove Using the oven Cutting food safely Pouring hot liquids Organising food items Cleaning up after cooking

30. Are you able to prepare meals independently? Yes, independently Yes, with adaptations I need assistance No

Section 6 – Medication Management

31. Are you able to take your medication at the correct time and dosage? Yes Yes, with a pill organizer or reminder alarm I need assistance

32. How do you identify your medication?Check all that apply. Reading labels Braille labels Colour or shape Stored in a fixed location Pill organizer Mobile app or speech function Someone helps me

Section 7 – Orientation at Home

33. Do you have difficulty finding or navigating to…Check all that apply. Bathroom Kitchen Light switches Doors and door handles The correct cupboard or drawer Clothing and colours Food items in the refrigerator Remote control Telephone

34. Have you experienced any falls inside your home due to your vision? Yes No

Section 8 – Outdoor Mobility and Transportation

35. Are you able to travel outdoors independently? Yes Only on familiar routes I need someone to accompany me No

36. Do you experience difficulties with…Check all that apply. Curbs Outdoor stairs Bus stops Pedestrian crossings Shopping centres Stores Darkness or low-light conditions Snow or slippery surfaces Rain or poor visibility

37. Do you use a white cane? Yes Sometimes No, but I am considering it No

38. Do you drive? Yes I stopped driving because of my vision I have never driven

39. Do you need Orientation and Mobility (O&M) training? Yes No I am already receiving O&M training

Section 9 – Digital Life

40. Which digital apps and tools do you use?Check all that apply. Camera Magnifier OCR (Optical Character Recognition) Seeing AI Envision Be My Eyes Google Lookout Speech-to-Text (Dictation) Text-to-Speech Siri / Google Assistant I do not use any of these yet Other apps

41. Are you able to use online banking and public digital services?Examples: government services, healthcare portals, tax services, etc. Yes Partly No

Section 10 – Reading

42. What are you able to read, with or without assistive technology?Check all that apply. Books Newspapers Text messages (SMS) Email Food labels and packaging Recipes Television subtitles Restaurant menus Street signs and street names I am unable to read print

Section 11 – Psychosocial Well-being

43. Are you worried about…Check all that apply. Falling Walking alone outdoors Asking strangers for help Losing my independence Being a burden to others Losing my job Becoming more socially isolated

44. Do you experience your visual impairment as a significant emotional or psychological burden? Yes Sometimes No

45. Have you spoken with a psychologist, counsellor, or other mental health professional about your visual impairment? Yes No No, but I would like to

46. Are you a member of a blindness or vision loss organisation? Yes No No, but I am interested

47. Additional comments about your well-being and quality of life

Section 12 – Work, Leisure and Daily Activities

48. What is your current employment status? Employed full-time Employed part-time On sick leave Receiving disability benefits Retired Other

49. Are you able to perform household tasks independently? Yes Partly No

50. Are you able to shop for groceries? Yes, independently I shop online I need assistance No

51. Have you stopped participating in any activities or hobbies because of your vision?

52. Do you have any other health conditions that affect your daily life?

Section 13 – Vision Rehabilitation Specialist’s Observations

53. ObservationsCheck all that apply. Unusual head posture Short or long working distance Specific reading strategies Need for improved lighting Need for improved contrast Orientation difficulties Difficulty with visual scanning Reduced visual endurance Need for vision rehabilitation training Need for referral to other services

54. Additional observation notes

55. Assessment of strengths, resources and rehabilitation potential

56. Recommendations for further referral

Section 14 – Priority Recommendations and Action Plan

57. Key findings from the assessment

58. Action Plan

Action	Responsible Person	Target Date	Priority

Example: Within 2 weeks

59. Date of the next evaluationmm/dd/yyyy

Your email address (optional – to receive a copy of this form)