Pre-Assessment Questionnaire

Thank you for choosing Home Modifications Solutions.

The information you provide below will help us better understand your current concerns, goals, and home environment before your scheduled Home Safety Assessment.

Please complete this questionnaire to the best of your ability. You do not need to provide detailed medical information. We will discuss your specific needs during your assessment.

All information provided will be treated as strictly confidential and used solely for the purpose of preparing for and conducting your Home Safety Assessment and related services.

Section1- CLIENT INFORMATION