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Bathroom Checklist Living Areas Checklist Kitchen Checklist Hallways and Stairs Checklist Porch and Yard Checklist Personal Risk Factors Checklist

Answer all 6 questions and press GO!

1. Is there a long reach from the bed to a light?
Yes     No
2. Is it necessary to get out of bed or reach far to get to the telephone?
Yes     No
3. Is it necessary to get out of bed or reach far to get eyeglasses?
Yes     No
4. Are there telephone, light, or television cords running along the floor on the walkways?
Yes     No
5. Is there clutter (clothes, shoes, books, etc.) on the floor?
Yes     No
6. Is it common to get up many times during the night to use the bathroom?
Yes     No