Home Visit

Impairments/immobility

Any indication of cognitive impairment?

Advanced activities of daily living (select all that apply)

Specify other

Activities of daily living (select all that apply)
Any issues with balance and gait (select all that apply)

Sensory impairments (select all that apply)

Falls?

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)
Other people

Is there a caregiver?

Who?

Tasks of the caregiver

Hours of caregiving per day

Stress?

Coping?

Abuse?

Need for respite?

Physically or emotionally capable?

Social supports?

Advanced directives?

Power of attorney?

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?

Height

Blood pressure

Glucose

Urinalysis

Other

Mini-Mental State Examination

Depression screening

General physical condition

Focused examination

Safety

Access to emergency services

Alternative power source if needed

Adaptations to home needed

Telephone availability

Bathroom

Kitchen

Carpets

Lighting

Electrical cords

Stairs

Tables, chairs, and other furniture

Hot water heater

Fire and smoke detectors

Fire extinguishers

Emergency plans

Evacuation route

Gas or electric range

Heating/air-conditioning

Water source

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
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.