Home Safety Questionnaire

Home Assessment Questionnaire


Yes    No

___   ___   Does your home have more than 1 level?


___   ___   Are there stairs by the home entrances or within the home?


___   ___   Do you have a bath tub?


___   ___   Are there grab bars in the bathroom?


___  ___    Is there a step into your shower? Is there a seat inside the shower?


___   ___   Is it difficult to raise up from the toilet because it is too low?


___   ___  Can you reach all shelving in kitchen cabinets safely?


___   ___  Do you have room to maneuver around your kitchen safely?


___   ___  Is your house well lit? Are there dark rooms or areas within your home that make it difficult for you to see objects/furniture?


___  ___  Are your doorways and hallways wide enough to accommodate a wheel chair or walker?


___ ___   Is there a fire extinguisher, fire alarm and carbon monoxide alarm located within your home?


___ ___  Are all handles on doors lever style handles?


___  ___ Are the oven knobs located on the front of the oven?


___  ___   Is your carpet pile ½ inch or less or berber style carpet?


___  ___   Do you have a front loading washing machine and dryer?


___  ___   Are there fluorescent lights in your laundry area?


___  ___   Are there any thresholds by doorways that are over ½ inch?





“Creating Your Home… For Life”



(407) 595-3342 Fax: (208) 567-9757      Email: Aginginplacesafely@yahoo.com      

Website: www.aginginplacesafelyconsulting.com


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