Home Visit Checklist

• Reference #

• Location
  Address

• Conducted by

• Conducted on

  Date

Impairments/immobility

• Any indication of cognitive impairment?

  Yes

  No

• Advanced activities of daily living (select all that apply)

  Select Employment/volunteering Reading Music Socialization Hobbies Other

  • Employment/volunteering
  • Reading
  • Music
  • Socialization
  • Hobbies
  • Other

• Specify other

• Activities of daily living (select all that apply)

  Select Ambulating Toileting Transferring Bathing Feeding Continence Dressing

  • Ambulating
  • Toileting
  • Transferring
  • Bathing
  • Feeding
  • Continence
  • Dressing

• Any issues with balance and gait (select all that apply)

  Select Balance - Static (Romberg test, standing reach test) Balance - Dynamic (walking, tandem walk) Gait - Left: arm swing, stance, leg swing, step Gait - Right: arm swing, stance, leg swing, step

  • Balance - Static (Romberg test, standing reach test)
  • Balance - Dynamic (walking, tandem walk)
  • Gait - Left: arm swing, stance, leg swing, step
  • Gait - Right: arm swing, stance, leg swing, step

• Sensory impairments (select all that apply)

  Hearing

  Vision

  Smell

  Taste

  Tactile

• Falls?

  Yes

  No

Nutrition

• Eating habits

• Variety and quality of food

• Pantry

• Refrigerator

• Freezer

• Nutritional status

• Obesity

• Malnutrition

• Other

• Fluid intake

• Alcohol presence/use

• Swallowing difficulty

• Oral health

Home Environment

• Neighborhood

• Exterior of home

• Interior of home (select all that apply)

  Select Crowding Good housekeeping Hominess Privacy Pets Books Television Memorabilia Internet Information and communication technology

  • Crowding
  • Good housekeeping
  • Hominess
  • Privacy
  • Pets
  • Books
  • Television
  • Memorabilia
  • Internet
  • Information and communication technology

Other people

• Is there a caregiver?

  Yes

  No

• Who?

• Tasks of the caregiver

• Hours of caregiving per day

• Stress?

• Coping?

• Abuse?

• Need for respite?

• Physically or emotionally capable?

• Social supports?

  Yes

  No

• Advanced directives?

  Yes

  No

• Power of attorney?

  Yes

  No

• Who?

• Financial resources

• Patient attitude

Medications

• Prescription drugs

• Nonprescription drugs

• Dietary supplements

• Medications organized

• Medication compliance

• Medication discrepancy

• Multiple prescribers

• Allergies to medications

• Written instructions

Examination

• Weight

• Weight loss?

  Yes

  No

• Height

• Blood pressure

• Glucose

• Urinalysis

• Other

• Mini-Mental State Examination

• Depression screening

• General physical condition

• Focused examination

Safety

• Access to emergency services

  Yes

  No

• Alternative power source if needed

  Yes

  No

• Adaptations to home needed

  Yes

  No

• Telephone availability

  Yes

  No

• Bathroom

  Yes

  No

• Kitchen

  Yes

  No

• Carpets

  Yes

  No

• Lighting

  Yes

  No

• Electrical cords

  Yes

  No

• Stairs

  Yes

  No

• Tables, chairs, and other furniture

  Yes

  No

• Hot water heater

  Yes

  No

• Fire and smoke detectors

  Yes

  No

• Fire extinguishers

  Yes

  No

• Emergency plans

  Yes

  No

• Evacuation route

  Yes

  No

• Gas or electric range

  Yes

  No

• Heating/air-conditioning

  Yes

  No

• Water source

  Yes

  No

Spiritual health

• Spiritual includes cultural and ethnic influences

Services

• e.g. fire, police, emergency medical services, home health, social services, meals on wheels, hospice, transportation, legal, equipment, health benefit advisor

Completion

• Comments/Recommendations

• Conducted by: Name & Signature

  Sign