Patient Assessment Tool--Home Safety Checklist

Date: _____________ Name: ___________________________________________________
Any "no" answers indicate a potentially dangerous situation in your home.
Try to correct them AS SOON AS POSSIBLE to prevent a fall or other accident!
Circle either Y (yes) or n (no) for each of the following items:

HOUSEKEEPING

  1. Y | n : Do you clean up spills as soon as they occur?
  2. Y | n : Do you keep floors and stairways clean and free of clutter?
  3. Y | n : Do you put away books, magazines, sewing supplies and other objects as soon as you're through with them and never leave them on floors or stairways?
  4. Y | n : Do you store frequently used items on shelves that are within easy reach?

FLOORS

  1. Y | n : Do you keep everyone from walking on freshly washed floors before they're dry?
  2. Y | n : If you wax floors, do you apply 2 thin coats and buff each thoroughly or else use self-polishing, nonskid wax?
  3. Y | n : Do all small rugs have nonskid backings?
  4. Y | n : Have you eliminated small rugs at the tops and bottoms of stairways?
  5. Y | n : Are all carpet edges tacked down?
  6. Y | n : Are rugs and carpets free of curled edges, worn spots and rips?
  7. Y | n : Have you chosen rugs and carpets with short, dense pile?
  8. Y | n : Are rugs and carpets installed over good-quality, medium-thick pads?

BATHROOM

  1. Y | n : Do you use a rubber mat or nonslip decals in the tub or shower?
  2. Y | n : Do you have a grab bar securely anchored over the tub or on the shower wall?
  3. Y | n : Do you have a nonskid rug on bathroom floor?
  4. Y | n : Do you keep soap in an easy-to-reach receptacle?

TRAFFIC LANES

  1. Y | n : Can you walk across every room in your home, and from one room to another, without detouring around furniture?
  2. Y | n : Is the traffic lane from your bedroom to the bathroom free of obstacles?
  3. Y | n : Are telphone and appliance cords kept away from areas where people walk?

LIGHTING

  1. Y | n : Do you have light switches near every doorway?
  2. Y | n : Do you have enough good lighting to eliminate shadowy areas?
  3. Y | n : Do you have a lamp or light switch within easy reach from your bed?
  4. Y | n : Do you have night lights in your bathroom and in the hallway leading from your bedroom to the bathroom?
  5. Y | n : Are all stairways well lighted?
  6. Y | n : Do you have light switches at both the tops and bottoms of stairways?

STAIRWAYS

  1. Y | n : Do securely fastened handrails extend the full length of the stairs on each side of stairways?
  2. Y | n : Do rails stand out from the walls so you can get a good grip?
  3. Y | n : Are rails distinctly shaped so you're alerted when you reach the end of a stairway?
  4. Y | n : Are all stairways in good condition, with no broken, sagging or sloping steps?
  5. Y | n : Are all stairway carpeting and metal edges securely fastened and in good condition?
  6. Y | n : Have you replaced any single-level steps with gradually rising ramps or made sure such steps are well lighted?

LADDERS AND STEP STOOLS

  1. Y | n : Do you have a sturdy step stool that you use to reach high cupboard and closet shelves?
  2. Y | n : Are all ladders and step stools in good condition?
  3. Y | n : Do you always use a step stool or ladder that's tall enough for the job?
  4. Y | n : Before you climb a ladder or step stool, do you always make sure it's fully open and that the stepladder spreaders are locked?
  5. Y | n : When you use a ladder or step stool, do you face the steps and keep your body between the side rails?
  6. Y | n : Do you avoid standing on top of a step stool or climbing beyond the second step from the top on a stepladder?

OUTDOOR AREAS

  1. Y | n : Are walks and driveways in your yard and other areas free of breaks?
  2. Y | n : Are lawns and gardens free of holes?
  3. Y | n : Do you put away garden tools and hoses when they're not in use?
  4. Y | n : Are outdoor areas kept free of rocks, loose boards and other tripping hazards?
  5. Y | n : Do you keep outdoor walkways, steps and porches free of wet leaves and snow?
  6. Y | n : Do you sprinkle icy outdoor areas with deicers as soon as possible after a snowfall or freeze?
  7. Y | n : Do you have mats at doorways for people to wipe their feet on?
  8. Y | n : Do you know the safest way of walking when you can't avoid walking on a slippery surface?

FOOTWEAR

  1. Y | n : Do your shoes have soles and heels that provide good traction?
  2. Y | n : Do you wear house slippers that fit well and don't fall off?
  3. Y | n : Do you avoid walking in stocking feet?
  4. Y | n : Do you wear low-heeled oxfords, loafers or good-quality sneakers when you work in your house or yard?
  5. Y | n : Do you replace boots or galoshes when their soles or heels are worn too smooth to keep you from slipping on wet or icy surfaces?

PERSONAL PRECAUTIONS

  1. Y | n : Are you always alert for unexpected hazards such as out-ot-place furniture?
  2. Y | n : If young grandchildren visit, are you alert for children playing on the floor and toys left in your path?
  3. Y | n : If you have pets, are you alert for sudden movements across your path and pets getting underfoot?
  4. Y | n : When you carry bulky packages, do you make sure they don't obstruct your vision?
  5. Y | n : Do you divide large loads into smaller loads whenever posssible?
  6. Y | n : When you reach or bend, do you hold onto a firm support and avoid throwing your head back or turning it too far?
  7. Y | n : Do you always use a ladder or step stool to reach high places and never stand on a chair?
  8. Y | n : Do you always move deliberately and avoid rushing to answer the phone or doorbell?
  9. Y | n : Do you take time to get your balance when you change position from lying down to sitting and from sitting to standing?
  10. Y | n : Do you hold onto grab bars when you change position in the tub or shower?
  11. Y | n : Do you keep yourself in good condition with moderate exercise, good diet, adequate rest and regular medical checkups?
  12. Y | n : If you wear glasses, is your prescription up to date?
  13. Y | n : Do you know how to reduce injury in a fall?
  14. Y | n : If you live alone, do you have daily contact with a friend or neighbor?
Formatted and posted to the World Wide Web on 8/17/96 by
Robert S. Stall, M.D., Internist/Geriatrician (click here to send Dr. Stall E-mail),
with permission from the
National Safety Council
(708) 285-1121