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

 

Leave a Reply

Name *
Email *
Website