Use this worksheet to notice questions and plan changes. It is not a score or a professional home assessment. Work through it at your own pace and ask for help where needed.
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Name or household: ________________________ Date: ______________
Entrance, stairs, and walking routes
- Walkways are clear of loose items, cords, and footwear.
- Loose rugs or damaged flooring have been noted for attention.
- Stairs and changes in level are easy to see.
- Handrails and lighting have been checked or listed for help.
Bedroom and bathroom
- A light is within reach of the bed.
- The route to the bathroom is clear.
- Bathroom support needs can be discussed with a qualified person.
- Wet or slippery areas have been noted for action.
Kitchen and living areas
- Frequently used items can be reached comfortably.
- Heavy moving or installation tasks have been assigned to someone who can help.
- There is a convenient way to contact someone if needed.
My next steps
| Task or question | Who can help | When |
|---|---|---|
| ________________ | ________________ | ________ |
| ________________ | ________________ | ________ |
| ________________ | ________________ | ________ |
Keep this with the room-by-room guide. Discuss falls, unsteadiness, or individual equipment needs with an appropriate professional.
Further reading: National Institute on Aging: home safety · National Institute on Aging: room-by-room guidance