HOME VISIT RISK ASSESSMENT TOOL
Name
Address
Phone Number
Format: (00) 0000 0000.
Mobile Number
Format: 0000 000 000.
Date of Home Visit
/
Day
/
Month
Year
Date
Type of residence
House
Flat/Unit
Aged Care Facility
SRS
Other
Ensuring access to property and Client
1. Are the street signs or property number hidden from view?
Please Select
No
Yes
YES answers require further information/actions:
2. Is your home hidden from the street?
Please Select
No
Yes
YES answers require further information/actions:
3. Will we be able to park close to your home?
Please Select
No
Yes
NO answers require further information/actions:
4. Are there any uneven/dangerous or slippery steps/paths leading to your home?
Please Select
Yes
No
YES answers require further information/actions:
5. Will someone be able to open the front door?
Please Select
Yes
No
NO answers require further information/actions:
6. Do you require another person present during the consultation? For eg. Carer, Family member, interpreter?
Please Select
Yes
No
YES answers require further information/actions:
7. Is there mobile phone coverage at your home?
Please Select
Yes
No
NO answers require further information/actions:
ANIMALS /PETS
8. Do you have any animals at home? They may need to be restrained/isolated before the home visit?
Please Select
Yes
No
YES answers require further information/actions:
OCCUPANTS
9. Who do you normally live with at this address?
Alone
Partner
Carer
Parent
Children
Shared
Other
10. Will anyone else be home when we visit?
For eg. husband, mother, child, grandparent, friend etc
11. Does anyone at home take drugs or drink a lot of alcohol?
Please Select
Yes
No
YES answers require further information/actions:
12. Does anyone smoke at home?
Please Select
Yes
No
YES answers require further information/actions:
13. Is there anyone at home with contagious illness?
Please Select
Yes
No
YES answers require further information/actions:
14. Is there anyone in the home who has a history of violent or aggressive behaviour?
Please Select
Yes
No
YES answers require further information/actions:
HAZARDS
15. Do you have any weapons or guns at home?
Please Select
Yes
No
YES answers require further information/actions:
16. Any additional hazards identified?
COVID-19
17. Is there anyone in the home who has a positive RAT or PCR Covid-19 test result in the last 7 days?
Please Select
Yes
No
YES answers require further information/actions:
18. Is there anyone in the home who is displaying symptoms of Covid-19? For eg. fever, sore throat, cough etc
Please Select
Yes
No
YES answers require further information/actions:
OUTCOME
No risks identified
Proceed with home visit as scheduled
Risks Identified
Discussed with client-action taken-Proceed with home visit as scheduled
Risk identified which precludes home visit as an option
Action taken:
Dietitian Name
Date
/
Month
/
Day
Year
Date
Dietitian Signature
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