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Home Assessment Pre Visit Questionnaire

Sent to the client before an in-home safety and wellbeing visit takes place. It covers general health, recent falls, medication, exercise habits and everyday difficulties, then moves on to the layout of the house, including stairs, bathrooms and grab bars. The assessor arrives already prepared.

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Full Name*

Nombre

Apellido

Gender*

Female Male Non-binary Prefer not to say

E-mail*

Address*

Dirección

Ciudad

Estado / Provincia

Código postal

Phone Number

Date of Birth*

What are the main reasons you are seeking a home assessment?*

Fall prevention Mobility support Recovery after surgery Managing a chronic condition Staying safely at home Requested by a relative or carer

What are your goals for the home and health assessment?

How do you rate your current level of health?

Not likely

1 2 3 4 5 6 7 8 9 10

Very likely

Have you fallen in the past year? If so, how many times? Where were you when the fall(s) occurred?

Please list any medical diseases/conditions you have been diagnosed with by your doctor.

Do you have a family history of diabetes, cardiovascular disease, cancer, or any other major illness?

Please list any prescribed medications you are currently taking (e.g. warfarin, laxatives)

Do you exercise?

Yes, daily Yes, several times a week Occasionally No

Please list the types of exercise you do regularly

Do you have any difficulty with the following:

Walking Climbing stairs Bathing Dressing Cooking Getting out of bed None of these

Additional information you want to share?

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What type of home do you live in?

House Apartment Condominium Mobile home Retirement village Shared accommodation

Do you have stairs to enter or navigate within your home?

Do you have access to a bathroom on the main level of your home?

Do you have grab bars in your bathroom?

Where do you spend most of your time in your house?

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