Title Page

  • Reference #

  • Location
  • Conducted by

  • Conducted on

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?


  • Comments/Recommendations

  • Conducted by: Name & Signature

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