You can always press Enter⏎ to continue
Taker the Home Fall Risk Questionnaire
For families considering home access, and home safety measures for their loved ones.
13
Questions
START
1
Do you have throw rugs on the floor?
Remove the rugs, or use double-sided tape, or non-slip backing so the rugs won't slip.
YES
NO
Previous
Next
Submit
Press
Enter
2
Do you have to walk over / around wires or cords?
Coil or tape cords and wires next to the wall so you can’t trip over them. If needed, have an electrician put in another outlet.
YES
NO
Previous
Next
Submit
Press
Enter
3
Is the tub or shower floor slippery?
Put a non-slip rubber mat or self-stick strips on the floor of the tub or shower.
YES
NO
Previous
Next
Submit
Press
Enter
4
Is there a handrail on only one side of the stairs?
Fix loose handrails, or put in new ones. Make sure handrails are on both sides of the stairs, and are as long as the stairs.
YES
NO
Previous
Next
Submit
Press
Enter
5
Do you have house pets?
Always be aware of nearby pets, who may serve as tripping hazards.
YES
NO
Previous
Next
Submit
Press
Enter
6
Do you need some support when you get in/out of the tub, or up from the toilet?
Have grab bars put in next to and inside the tub, and next to the toilet.
YES
NO
Previous
Next
Submit
Press
Enter
7
Do you use an oxygen concentrator or tank with a long tubing?
Always be aware of loose tubing, and avoid dragging on the floor behind you.
YES
NO
Previous
Next
Submit
Press
Enter
8
Are there papers, shoes, books, or other objects on the stairs?
Always keep objects off the stairs, and avoid general clutter.
YES
NO
Previous
Next
Submit
Press
Enter
9
Your Name
Previous
Next
Submit
Press
Enter
10
What questions do you have?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
Previous
Next
Submit
Press
Enter
11
Would you like a home accessibility consultant to reach out to you and assess your home's accessibility needs?
YES
NO
Previous
Next
Submit
Press
Enter
12
Phone Number
Area Code
Phone Number
Previous
Next
Submit
Press
Enter
13
Ok thank you, where should we send your questionnaire results?
example@example.com
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
13
See All
Go Back
Submit