A Home Environmental Assessment printable pdf download

Taking Action to Prevent Falls: A Home Environmental Assessment

Name of Assessor _______________________

Assessor Background (e.g., social worker, care manager, etc.) _____________________________

Client Name_______________________________

Date____________________

Hello, my name is ________ and I am from ________. As part of (your program's name), I am here today to help you identify hazards in the home that may increase the risk of falling and to offer recommendations.

Will you show me around your house?

Taking Action: Identifying Problems and Potential Solutions Within the Home

Directions: Walk through the home with the client and together, observe and identify any problems. If the client indicates difficulties in any daily task (e.g., going up and down stairs), observe the client performing

this task. Circle "yes" if the problem is present, "no" if the problem is not present, and "N/A" if the problem does not apply in the home (e.g., no stairs inside the home or the room is not used). Following the walk-

through, sit down with the client and discuss the findings and potential solutions. Through a collaborative process, encourage clients to identify what solutions are needed and would work best for them. Write down

the solutions that the client agrees to. In the next column, identify the person who will perform the necessary action (e.g., client, family member, assessor, handyman, etc) or write "no action" if the client does not

need or want to implement the solution. Use the comments section to note any additional information (e.g., specify which bathroom has problems, reasons for non-compliance, describe problem with handrails).

Problems

Yes, No, N/A

Potential Solutions

Solutions Agreed To:

Action By:

Comments:

Gardening tools on porch near

front door. Client don't feel

Move objects to the side

Client

Example: Objects blocking entrance/pathway

N N/A

Remove objects

this is a problem, but agrees to

move.

Pathways/Entrance to Home

Objects blocking entrance/pathway

N N/A

Remove objects

Repair loose, uneven surfaces

N N/A

Loose, uneven surfaces

Provide better/brighter lighting; or mark

Poor visibility

N N/A

stairs

Install handrail along full length of stairs

Handrails broken or absent on both sides of

N N/A

stairs

on both sides

Absence of a ramp

N N/A

Install ramp

Hallways

Use double-sided carpet tape on secure

Loose throw rugs, runners, or mats

N N/A

rugs; or remove them

Carpet folds or frayed carpet

N N/A

Tack down loose carpet

Pathways not clear: small objects, cords, papers,

N N/A

Clean up clutter; or move objects

books in way of foot traffic

Lighting dim or inadequate

N N/A

Provide better, brighter lighting

A Home Environmental Assessment

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