Home Visit Assessment Checklist

• Reference #

• Location
  Address

• Conducted by

• Conducted on

  Date

Bathroom

• Are handholds sturdy and in appropriate places?

  Yes

  No

• Can the toilet seat be raised?

  Yes

  No

• Does the bathtub/shower have a nonslip surface?

  Yes

  No

• Is the bathroom floor slick?

  Yes

  No

Electrical cords/appliances

• Are cords frayed or damaged?

  Yes

  No

• Do cords cross walking paths?

  Yes

  No

Emergency actions/evacuation route

• Are emergency numbers available?

  Yes

  No

• Are there means of egress from home?

  Yes

  No

Firearms

• Are firearms present?

  Yes

  No

• If yes, are they secured? (e.g., gun lock, locked case/cabinet, weapon and ammunition separated)

  Yes

  No

Fire extinguishers

• Are fire extinguishers present?

  Yes

  No

• If yes, are they accessible and in working order?

  Yes

  No

• Is the patient or caregiver able to use them?

  Yes

  No

Heating and air-conditioning

• Are controls accessible and easy to read?

  Yes

  No

• Is the home an appropriate temperature year-round?

  Yes

  No

Hot water heater

• Temperature set below 120° F (49°C)?

  Yes

  No

Kitchen safety (especially gas stoves)

• Is it easy to tell if burner or oven gas is on?

  Yes

  No

• Does the patient wear loose garments while cooking?

  Yes

  No

Lighting and night-lights

• Is lighting present and sufficient?

  Yes

  No

Loose carpets and throw rugs

• Are carpets and throw rugs present?

  Yes

  No

• If yes, do they need to be secured or removed?

  Yes

  No

Pets

• Are pets present?

  Yes

  No

• If yes, are they easy to care for?

  Yes

  No

Smoke and carbon monoxide monitors

• Are they present?

  Yes

  No

• If yes, are they functioning and monitored?

  Yes

  No

Stairs

• Does the home have stairs?

  Yes

  No

• If yes, are they carpeted and is the carpeting secure?

  Yes

  No

• Are stairs well lit?

  Yes

  No

• Are there railings?

  Yes

  No

Tables, chairs, furniture

• Is furniture sturdy, balanced, and in good repair?

  Yes

  No

Utilities (gas or electric)

• Are the systems monitored and maintained?

  Yes

  No

Water source

• Is water from a public source or a well?

  Yes

  No

• Is the source functioning and safe?

  Yes

  No

Completion

• Comments/Recommendations

• Conducted by: Name & Signature

  Sign