Home Safety Checklist Today’s Date Patient Name
_________________
Survey Start Time
_____________________
DOB
_______
_______
End Time
_______
Gender
Male
Female
Yes
No
1
Did the patient sign the Consent Form?
2
What is your patient’s overall health status?
3
How many people live in the home? (indicate number and check the appropriate _________ box below) Spouse
Children
Relatives
Poor
Friends
Fair
Excellent
Other _________________________
4
Does the patient take medicines (prescription & nonprescription)?
5
How does the patient keep track of their medicines? Medicines lined up
Good
No method to keep track
Yes
No
“Pre-poured” or placed in a pillbox Other method:________________
Can the patient walk without the help of a person or assistive device?
Yes
No
7
Does patient keep any medicine in the home that he/she no longer takes?
Yes
No
8
Does the patient use a hearing aide?
Yes
No
9
Are there any areas with poor lighting?
Yes
No
10
Are there loose or worn-out rungs or carpets?
Yes
No
11
Are there uneven or slippery floors?
Yes
No
12
Is there any sign of mold or fungus?
Yes
No
13
Are there any dangerous space heater (uses flammables)
Yes
No
14
Are there dangerous electrical cords (risk of tripping over, overloaded outlets, damaged cords)
Yes
No
15
Are there excessive dust or animal hair
Yes
No
16
Are there any furniture blocking exits?
Yes
No
17
Are there any excessive clutters that might block exit routes?
Yes
No
18
Are foods stored in a sanitary manner?
Yes
No
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19
Is there any trash build-up
Yes
No
20
Are there any cleaning products and other potential poisons that are not in the original containers (original labels are not in place)
Yes
No
21
Are non-food and food items kept in same cabinet?
Yes
No
22
Are stove knobs hard to reach?
Yes
No
23
Are there any flammables near the stove (towels, curtains, or papers)
Yes
No
24
Are there any expired and rotten foods in the home?
Yes
No
25
Yes
No
Yes
No
27
Are there any threats of violence (aggressive pets, neighbors, or weapons) Are doors secured with proper locking mechanism (dead bolt, chain lock, peek hole) Are there any excessive loud noise (from outside or inside)
Yes
No
28
Are there any sign of pests in the home (cockroaches, spiders, ants)
Yes
No
29
Are there any signs of bugs in the home (bed bugs, lice, fleas)
Yes
No
Do you notice any bug bites on patient skin
Yes
No
30
Are there any signs of rats and mice in the home Do you notice unsafe use of smoking materials (example: ashtray by the bed, candles next to flammables)
Yes
No
Yes
No
32
Is there a Carbon Monoxide alarm in the home
Yes
No
33
Is there properly working smoke alarms in the home
Yes
No
34
Are grab-bars installed in the bathroom/showers
Yes
No
35
Are there fire extinguishers in the home
Yes
No
36
Are fire extinguisher charged
Yes
No
37
Are there non-slip shower- mat or pads in the shower/tub
Yes
No
38
Are there non-slip rugs on the bathroom floors
Yes
No
39
Is there a list of emergency contacts available
Yes
No
Yes
No
Yes
No
Yes
No
26
31
40 41
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If the patient uses a mechanical lift, is the patient/caregiver trained on uses/maintenance/ and handling of the lifting mechanism) If the patient uses Oxygen, has she/he been trained on use/storage/maintenance and handling of equipments? If the patient uses commode, is the patient/caregiver trained on use/maintenance/and handling of the commode?
43 44 45 46 47 48
If the patient uses wheelchair, is the patient/caregiver trained on use/maintenance/ and handling of the wheelchair? If the patient uses a cane, is the patient/caregiver trained on use/maintenance/ and handling of the cane? If the patient uses needles and sharps, is there a sharp container in the home (not full)? If the patient uses a ventilator, is the patient/caregiver trained on use, maintenance, and handling of the ventilator? If the patient uses a nebulizer, is the patient/caregiver trained to use/maintain/ and handling of the nebulizer? If the patient uses a walker, is the patient /caregiver trained on use/maintenance, and handling of the walker?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
49
Was the patient interested in your evaluation of the home safety
Yes
No
50
Did your experience any difficulty assessing the home site for safety
Yes
No
Additional Comments: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
_________________________
Title
__________________
Signature
_________________________
Date
________________
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Assessors Name
B. Hazardous conditions and safety risks 12. Mold or Fungus
10. Loose or worn-out rugs or carpets
13. Dangerous space heater (uses flammables)
11. Uneven or Slippery floors
14. Dangerous electrical cords
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9. Poor Lighting
15. Excessive dust or animal hair
18. Food sanitation
19. Trash build up
17. Excessive clutter
20. Products not in original container (missing labels)
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16. Furniture blocking exits
24. Rotten food or milk in the home
22. Stove knobs hard to reach
25. Threat of violence, aggressive dogs, other pets, neighbors, or weapons
23. Flammables near stove tops
26. Doors and locks
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21. Non-food and food items in same cabinet
27. Excessively loud noise
30. Signs of rats or mice in the home
28. Signs of cockroaches in the home
31. Unsafe use of smoking materials
29. Signs of other bugs in the home like bed bugs, fleas, or lice Bed Bug Bites
Lice
Flea Bites
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Bed Bugs
C. Safety Items 35. Fire extinguisher in the home
33. Smoke alarm in the home
36. Is the pressure gauge arrow in the green section
34. Grab bars in/out of the shower/bathtub
37. Non-slip shower mat or pads
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32. Carbon monoxide alarm in the home
38. Non-slip rug on the bathroom floor
39. Emergency contacts list
D. Medical devices: 42. Portable toilet (Commode)
41. Oxygen tank
43. Wheelchair
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40. Lifting Device
44. Cane
47. Nebulizer
45. Needles and sharps
48. Walker
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46. Ventilator