This document is a comprehensive checklist for evaluating the health, safety, and well-being of older adults. It includes sections on cognition, demographics, social support, finances, psychological health, physical health, medications, activities of daily living, and home safety. The evaluator is instructed to ask the older adult a series of questions in each section and check off or record their responses. The goal is to identify any needs or risks and ensure they have support.

1. Home Safety Checklist
Use this checklist as you walk through each room in your home
and check for hazards. You should check off each item in this
list (when applicable to your home). If you are unable to check
off an item, be sure to fix it within an appropriate time frame.
Kitchen
· Have a sturdy step stool with handrails, or a utility ladder to
reach high cabinets or shelves.
· Hazardous products (household cleaners, disinfectants and
insecticides) are stored in their original labeled containers
separate from food
· Knives are kept in a special rack or compartment
· Oven mitts, pot holders and towels are stored away from the
stove
· Pot handles are always turned away from the front of the stove
· The pressure gauge on a fire extinguisher is checked monthly
– if the needle is in green it is still good, if the needle is
anywhere else, replace
· Fire extinguisher is mounted on a bracket on the wall near an
Bathroom
· Have a slip-resistant surface in the shower or tub
· Grab bars are installed in bathrooms or shower stalls
· Electrical appliances are unplugged when not in use
· Slip-resistant rugs are in place on bathroom floors
Living Room
· Have a safety screen in place in front of fireplace
· Slip-resistant floor coverings and rugs on floor
· Walkways are clear of obstacles (toys, papers, shoes)
· Stairs, hallways and passageways are well lit
· Sturdy handrails installed on all steps and stairways
· Carpeting, stairway treads and risers are in good condition
· Electrical cords are secured
· TVs are properly secured to walls or in or on a sturdy cabinet

2. Page 1 of 2
© 2014 National Safety Council
Smoke detectors
Every month:
Test them
Every year: Change the batteries
Every 10 years: Replace the entire unit
© 2014 National Safety Council
Bedrooms
· Phone and flashlight are located near beds
· Lamp or light switch is within reach of bed
· Bed frame is against wall without gaps
· Smoke detectors and carbon monoxide detectors are outside of
sleeping area, with working battery
· Walkway and all exit routes are clear of clutter
Basement or utility room
· Working smoke detector located in basement and every other
floor
· Gas and water lines are tagged (so you can turn them off in an
emergency)
· Location of main electrical switch is known
· It is known how to light the pilot on your gas furnace and
water heater
· Washer and dryer are electrically grounded

3. · Tools are properly stored and out of reach of children
· Have an emergency kit in case of hazardous weather
Garage and driveway
· Power tools and hazardous chemicals are locked away in
cabinets
· Flammable materials (gasoline or oil-soaked rags) are stored
in appropriate safety containers
· It is known to never turn on your vehicle or other gas-powered
equipment with the garage door closed
· Garage and driveway are well maintained and free of slip and
trip hazards, such as cracks or uneven surfaces Outside the
house
· Lighting in place around steps, walkways, patios and
driveways
· Children’s play equipment, (slides, swing set) are securely
anchored
· If you have a pool, it is covered or surrounded by a high fence
· Trees and shrubs around your home are maintained by
trimming overhanging branches and removing leaves from
gutters
· Heavy snow is removed from the roof with a roof rake
Page 2 of 2
Comprehensive Older Person's Evaluation
Comprehensive Older Person's Evaluation
Comprehensive Older Person’s Evaluation
Name (print):
__Jacob______________________________________________
______________________ Date of Visit:
_________________________

4. Chief complaint:
_______Hypertension___________________________________
_____________________________________________________
_____________
Today I will ask you about your overall health and function and
will be using a questionnaire to help me obtain this information.
The first few questions are to check your memory.
Preliminary Cognition Questionnaire:Record if answer is correct
with ( ); if answer is incorrect, with ( ). Record total number of
errors.
( , )
1) What is the date today? ______
2) What day of the week is it? ______
3) What is the name of this place? ______
4) What is your telephone number or room number? (record
answer: _______) ______
If subject does not have phone, ask:
What is your street address?
5) How old are you? (record answer: _______) ______
6) When were you born? (record answer from records if patient
cannot answer: _______) ______
7) Who is the president of the United States now? ______
8) Who was the president just before him? ______
9) What was your mother’s maiden name? ______
10) Subtract 3 from 20 and keep subtracting from each new
number you get, all the way down. ______
Total errors ______
If more than 4 errors, ask #11. If more than 6 errors, complete
questionnaire from informant.
11) Do you think you would benefit from a legal guardian,
someone who would be responsible for your legal and financial
matters?
Do you have a living will? Would you like one?
a) No
b) Has functioning legal guardian for sole purpose of
managing money

5. (describe:
_____________________________________________________
_________________)
c) Has legal guardian
d) Yes
Demographic Section
1) Patient’s race or ethnic background (record:
_______________)
2) Patient’s gender (circle) Male Female
3) How far did you go in school?
a) Postgraduate education
b) Four-year degree
c) College or technical school
d) High school complete
e) High school incomplete
f) 0-8 years
Social Support Section: Now there are a few questions about
your family and friends.
4) Are you married, widowed, separated, divorced, or have you
never been married?
a) Now married
b) Widowed
c) Separated
d) Divorced
e) Never married
5) Who lives with you? (circle all responses)
a) Spouse
b) Other relative or friend (specify:
_______________________)
c) Group living situation (non-health)
d) Lives alone
e) Nursing home, number of years
6) Have you talked to any friends or relatives by phone during
the last week?
a) Yes

6. b) No
7) Are you satisfied by seeing your relatives and friends as
often as you want to, or are you somewhat dissatisfied about
how little you see them?
a) Satisfied (skip to #8)
b) No (ask A)
A) Do you feel you would like to be involved in a
Senior Citizens Center for social events, or perhaps meals?
1) No
2) Is involved (describe:
_________________________)
3) Yes
8) Is there someone who would take care of you for as long as
you needed if you were sick or disabled?
a) Yes (skip to C)
b) No (ask A)
A) Is there someone who would take care of you for a
short time?
1) Yes (skip to C)
2) No (ask B)
B) Is there someone who could help you now and
then?
1) Yes (ask C)
2) No (ask C)
C) Whom would we call in case of an emergency?
(record name and telephone: ______________________
________________________________________________)
Financial Section
9) Do you own, or are you buying, your own home?
a) Yes (skip to #10)
b) No (ask A)
A) Do you feel you need assistance with housing?
1) No
2) Has subsidized or other housing assistance
3) Yes (describe:
________________________________)

7. B) What type of housing did you have prior to coming
here?
10) Are you covered by private medical insurance, Medicare,
Medicaid, or some disability plan? (circle all that apply)
a) Private insurance (specify and skip to #11): )
b) Medicare
c) Medicaid
d) Disability (specify and ask A:
_________________________)
e) None
f) Other (specify:
______________________________________)
A) Do you feel you need additional assistance with
your medical bills?
1) No
2) Yes
11) Which of these statements best describes your financial
situation?
a) My bills are no problem to me (skip to #12)
b) My expenses make it difficult to meet my bills
(ask A)
c) My expenses are so heavy that I cannot meet my
bills (ask A)
A) Do you feel that you need financial assistance
such as: (circle all that apply)
1) Food stamps
2) Social Security or disability payments
3) Assistance in paying your heating or electrical
bills
4) Other financial assistance (describe:
____________)
Psychological Health Section: The next few questions are about
how you feel about your life in general. There are no right or
wrong answers, only what best applies to you. Please answer
yes or no to each question.

8. Yes No
_____ _____
12) Is your daily life full of things that keep you
interested?
_____ _____ 13) Have you, at times, very much wanted to
leave home?
14) Does it seem that no one understands you? _____
_____
15) Are you happy most of the time? _____ _____
16) Do you feel weak all over much of the time? _____
_____
17) Is your sleep fitful and disturbed? _____ _____
18) Taking everything into consideration, how would you
describe your satisfaction with your life in general at the
present time—good, fair, or poor?
a) Good
b) Fair
c) Poor
19) Do you feel you now need help with your mental health; for
example, a counselor or psychiatrist?
a) No
b) Has (specify:
_______________________________________)
c) Yes
Physical Health Section: The next few questions are about your
health.
20) During the past month (30 days), how many days were you
so sick that you couldn’t do your usual activities, such as
working around the house or visiting with friends?
21) Relative to other people your age, how would you rate your
overall health at the present time: excellent, good, fair, poor, or
very poor?
a) Excellent (skip to #22)
b) Very good (skip to #22)
c) Good (ask A)
d) Fair (ask A)

9. e) Poor (ask A)
A) Do you feel you need additional medical services such
as a doctor, nurse, visiting nurse, or physical therapist? (circle
all that apply)
1) Doctor
2) Nurse
3) Visiting nurse
4) Physical therapist
5) None
22) Do you use an aid for walking, such as a wheelchair,
walker, cane, or anything else? (circle aid usually used)
a) Wheelchair
b) Other (specify:
______________________________________)
c) Visiting nurse
d) Walker
e) None
23) How much do your health troubles stand in the way of your
doing things you want to do: not at all, a little, or a great deal?
a) Not at all (skip to #24)
b) A little (ask A)
c) A great deal (ask A)
A) Do you think you need assistance to do your daily
activities; for example, do you need a live-in aide or
choreworker?
1) Live-in aide
2) Choreworker
3) Has aide, choreworker, or other assistance
(describe: ____________________________________)
4) None needed
24) Have you had, or do you currently have, any of the
following health problems? If yes, place an “X” in appropriate
box and describe; medical record information may be used to
help complete this section.

10. HX
CURRENT
DESCRIBE
a) Arthritis or rheumatism?
b) Lung or breathing problem?
c) Hypertension?
d) Heart trouble?
e) Phlebitis or poor circulation problems in arms or legs?
f) Diabetes or low blood sugar?
g) Digestive ulcers?
h) Other digestive problem?
i) Cancer?

11. j) Anemia?
k) Effects of stroke?
l) Other neurological problem?(specify: ___________)
m) Thyroid or other glandular problem? (specify:
___________)
n) Skin disorders such as pressure sores, leg ulcers, burns?
o) Speech problem?
p) Hearing problem?
q) Vision or eye problem?

12. r) Kidney or bladder problems, or incontinence?
s) A problem of falls?
t) Problem with eating or your weight? (specify:
___________)
u) Problem with depression or your nerves? (specify:
___________)
v) Problem with your behavior (specify: ______
____________________)
w) Problem with your sexual activity?
x) Problem with alcohol?
y) Problem with pain?

13. z) Other health problems?(specify: ___________)
Immunizations:
_____________________________________________
_____________________________________________________
____
25) What medications are you currently taking, or have been
taking, in the last month? (May I see your medication bottl es?)
(If patient cannot list, ask categories a-r and note dosage and
schedule, or obtain information from medical or pharmacy
records and verify accuracy with the patient.)
Allergies:
Rx (DOSAGE AND SCHEDULE)
a) Arthritis medication
b) Pain medication
c) Blood pressure medication
d) Water pills or pills for fluid
e) Medication for your heart
f) Medication for your lungs
g) Blood thinners

14. h) Medication for your circulation
i) Insulin or diabetes medication
j) Seizure medication
k) Thyroid pills
l) Steroids
m) Hormones
n) Antibiotics
o) Medicine for nerves or depression
p) Prescription sleeping pills
q) Other prescription drugs
r) Other nonprescription drugs
26) Many people have problems remembering to take their
medications, especially ones they need to take on a regular
basis. How often do you forget to take your medications? Would
you say you forget often, sometimes, rarely, or never?
a) Never c) Sometimes

15. b) Rarely d) Often
Activities of Daily Living: The next set of questions asks
whether you need help with any of the following activities of
daily living.
27) I would like to know whether you can do these activities
without any help at all, or if you need assistance to do them. Do
you need help to: (If yes, describe, including patient needs.)
YES
NO
DESCRIBE (INCLUDE
NEEDS)
a) Use the telephone?
b) Get to places out of walking distance (using transportation)?
c) Shop for clothes and food?
d) Do your housework?
e) Handle your money?
f) Feed yourself?

16. g) Dress and undress yourself?
h) Take care of your appearance?
i) Get in and out of bed?
j) Take a bath or shower?
k) Prepare your meals?
l) Do you have any problem getting to the bathroom on time?
28) During the past 6 months, have you had any help with such
things as shopping, housework, bathing, dressing, and getting
around?
a) Yes (specify:
________________________________________) b) No
Signature of person completing the form:
Reprinted with permission from Pearlman R: Development of a
functional assessment questionnaire for geriatric patients:
COPE, J Chronic Dis 40:85S-94S, 1987.
Elsevier items and derived items © 2012, 2008, 2004, 2000,
1996, 1992 by Saunders, an imprint of Elsevier Inc.

17. Elsevier items and derived items © 2012, 2008, 2004, 2000,
1996, 1992 by Saunders, an imprint of Elsevier Inc.
Elsevier items and derived items © 2012, 2008, 2004, 2000,
1996, 1992 by Saunders, an imprint of Elsevier Inc.