Schedule Consultation
Schedule Consultation

Home Safety Assessment

MM slash DD slash YYYY
Description
(ENVIRONMENT)
1. Safe and adequate food and water supplies
2. Stove and means for refrigeration present
3. Adequate heat and ventilation
4. Free from infestation
5. Pathways free of obstacles such as loose rugs, furniture, etc
6. Clean area exists in which to store medical supplies
7. Is cautious with heating pads
8. Has a working smoke detector
9. If uses oxygen, appropriate signs posted
Fire/Electrical
1. Fire exits available; warning devices installed
2. No overuse of extension cords / adequate electrical outlets available
3. Turn off oven and stove burners
4. Emergency telephone numbers posted by phone
5. Turns pot handles to back of stove
6. Uses space heaters cautiously
7. Does not smoke in bed
8. Oxygen precautions used
Bathroom Safety
1. No throw rugs
2. Safety bars present and in good condition
3. Lighting is adequate
4. Shower chair is sturdy and in good condition
Medication Use
1. Keeps all medications in original bottle or med box
2. Has a medication schedule
3. Home Safety Instructive Given
Clear Signature
MM slash DD slash YYYY
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