Home Visit Assessment


Are handholds sturdy and in appropriate places?

Can the toilet seat be raised?

Does the bathtub/shower have a nonslip surface?

Is the bathroom floor slick?

Electrical cords/appliances

Are cords frayed or damaged?

Do cords cross walking paths?

Emergency actions/evacuation route

Are emergency numbers available?

Are there means of egress from home?


Are firearms present?

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

Fire extinguishers

Are fire extinguishers present?

If yes, are they accessible and in working order?

Is the patient or caregiver able to use them?

Heating and air-conditioning

Are controls accessible and easy to read?

Is the home an appropriate temperature year-round?

Hot water heater

Temperature set below 120° F (49°C)?

Kitchen safety (especially gas stoves)

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

Does the patient wear loose garments while cooking?

Lighting and night-lights

Is lighting present and sufficient?

Loose carpets and throw rugs

Are carpets and throw rugs present?

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


Are pets present?

If yes, are they easy to care for?

Smoke and carbon monoxide monitors

Are they present?

If yes, are they functioning and monitored?


Does the home have stairs?

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

Are stairs well lit?

Are there railings?

Tables, chairs, furniture

Is furniture sturdy, balanced, and in good repair?

Utilities (gas or electric)

Are the systems monitored and maintained?

Water source

Is water from a public source or a well?

Is the source functioning and safe?



Conducted by: Name & Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.