Safely Aging in Place Home Safety Survey

This short survey helps you evaluate how safe and comfortable your home is for aging in place. It takes about 5 minutes.
At the end, you’ll receive your safety score and the option to request a free home safety evaluation.

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Safely Aging in Place Home Safety Survey

This short survey helps you evaluate how safe and comfortable your home is for aging in place. It takes about 5 minutes.
At the end, you’ll receive your safety score and the option to request a free home safety evaluation.

Contact Information

First Name *

Email Address *

Phone Number

Address0 / 180

Please list a trusted family member, friend, or caregiver who can receive a copy of your safety results or be contacted if follow-up is needed.

Loved One’s Name

Is this for yourself or someone you are caring for?

Loved One’s Phone

Loved One’s Email Address

Would you like them to receive a copy of your safety results via email?YesNo

🔒 We respect your privacy. Your information and your loved one’s contact details will only be used to share your survey results or schedule a requested safety evaluation. We do not share or sell any data.

Home Safety Questions

Instructions:

For each question, choose the option that best describes your home.

1. Are all hallways, stairs, and paths through rooms well lit and free of clutter?YesSomewhatNo

2. Do you ever hold onto walls, towel bars, or fixtures for support when stepping in or out of the tub or shower?YesSomewhatNo

3. Are throw rugs secured with non-slip backing or removed entirely?YesSomewhatNo

4. Are there grab bars near your toilet and in the shower/tub area?YesSomewhatNo

5. Is there a shower seat and handheld shower head available if needed?YesSomewhatNo

6. Would a raised toilet seat and/or a bidet help in the bathroom?YesSomewhatNo

7. Have you lost your balance or had a fall or near-fall around your home in the past year?YesSomewhatNo

8. Do all rooms have working smoke and carbon monoxide detectors?YesSomewhatNo

9. If you were to fall, do you have an emergency plan and an easy way to call for help?YesSomewhatNo

10. Have you stopped using parts of your home due to stairs or any other limitation?YesSomewhatNo

11. Have stairs become harder since a recent surgery, fall, or diagnosis?YesSomewhatNo

12. Have you stopped using certain entrances into your home because they are more challenging?YesSomewhatNo

13. Does your home’s entrance come off a raised porch or patio?YesSomewhatNo

Your Score

Total Score

✅Excellent!

Your home is very safe for aging in place. Keep up the great work!

⚠️Fair

Your home is fairly safe, but a few updates could make it even safer. Consider scheduling a free safety evaluation.

❌At Risk

There may be several safety concerns. We recommend a professional home safety evaluation soon.

Would you like a free home safety evaluation to identify improvements that could help you stay safe and independent?Yes, I’d like a free evaluationNo, thank you

Name

Email Address

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