1. Home Safety Education package by Kwong Wing Lam, SPTA 5/12/2016
Category Description Check
box
Doorways/Entrances/Exterior
Stairs(inside/outside)
 Go up withthe good leg;Go downwiththe surgical leg
 Handrailsbothsidesforsupportandsafety
 Contrastfloortape: alertsnomore stepsto be taken
 Arrange a chair at the top/bottomof the stairsforresting
□
Door width/Hall width
 Entrance door width: 32 inchminimum, 36inch preferable
 Hall width: 32 inchminimum, 40 inchpreferable
□
Entrance door threshold
 Absentor½ inchmaximum
 Wheelchairthresholdramprecommendedif needed
□
Entrance door stability
 Entrance door grab bar provide standingsupporttogetinand out of the
house
□
Living Room
Furniture  Make sure the furniture isstable forsupport:Anti-SkidPads □
Chair(height/stability)
 Chairheight:1-2 inch above knee;Use chairraisers if needed Chair
stability: Use self-stickFloorCare Pads if needed
 Arm restsbothsides forsupportand safety
□
Telephone
 Easy to reach andnumbersare big enoughtoread.
 Put a listof importantnumbersnearthe phone
□
Kitchen
Rug/carpet
 Remove carpetingif able ormake sure the carpet issecure to prevent
slipping:Rugpad/double sidedcarpettape
□
Cabinet
 Organizedessential needswithinthe range of reach (nottoolow,not
too high)
□
Countertop
 Wipe upany spillsimmediately
 Arrange chairsto prepare foodat kitchentable topreventprolonged
standing
□
Bathroom
Raisedtoiletseat  Easierto standup and sitdown □
Grab bars  For supportnearthe toiletandinthe shower /bathtub □
Showerseat  Minimizes prolongedstandinginthe shower □
Bathmats  Slip-resistantbackingtopreventslippingandfalling □
Bedroom
Bedside table
 Close toyour bedwitha lampand room tostore eyeglassesanda
phone
□
Bedheight  Bedheight:1-2 inchabove the knee;Install bed raisers if needed □
Bedside railing  To helpwithbedmobility (ex:scooting,rolling, sittingup) □
General
Non-slipsock/slipper  Preventsslipping □
Clutter  Remove anycluttertopreventthe riskof tripping/falling □
Light
 Use night-lightthroughoutyourhome toprovide enoughlightingat
night
□

2. Home Safety Education package by Kwong Wing Lam, SPTA 5/12/2016
Please complete the following questionnaire and return to therapist
Category Description
Assistive
Device
What assistive device does the patient have at home? (Check all that apply)
□ Pick Up Walker □ Rolling Walker □ Cane □ Crutch □ Bedside Railing
□ Bedside Commode □ Hospital Bed □ Raised Toilet Seat □ Seat Cushion
□ Tub bench / shower chair □ bathroom grab bars □ wheelchair
□ Other (Be specific):
__________________________________________________
Stairs
[Outside and
Inside]
Outside Stairs
How many?: Front: _____Back: _____
Railing? □ L □ R □ Both □ None
Height of one step? ______inches
Inside Stairs
How many?: Front: _____Back: _____
Railing? □ L □ R □ Both □ None
Height of one step? ______inches
Health Supplies
What health supplies does the patient use at home? (Check all that apply)
□ Diaper □ Gloves □ Oxygen □ Wound Care Supplies □ Safety Call Alarm
□ Other (Be specific):
_________________________________________________
Home Furniture
Assessment
Chair Height (Floor to seat): ______ in
Toilet Height (Floor to toilet): ______ in
Bed Height (Floor to bed): ______ in
Sofa Height (Floor to sofa seat): ______ in
Bathtub Height (Floor to bathtub): ______ in
Hallway Width: ______ in
Front Door Width (Inside frame): ______ in
Bathroom Door Width (Inside frame): ______ in
Video/ Pictures
Please take videotape/pictures of Assistive Devices, Stairs, Home Furniture,
Bedroom, Bathroom, and Front Entrance.
Please including yourself in the video/picture so that we can visualize the
exact object or scale.
Contact Person (Print Name):____________________________________________________________
Physical Therapist/OccupationalTherapist/Social Worker (Print Name):_________________________
Date: _________________