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Parkinson's Home Safety Audit
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23
Questions
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1
Name
SECTION 1: CONTACT INFORMATION
First Name
Last Name
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2
Email
SECTION 1: CONTACT INFORMATION
example@example.com
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3
Phone Number
SECTION 1: CONTACT INFORMATION
Area Code
Phone Number
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4
Address
SECTION 1: CONTACT INFORMATION
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Who is this assessment for?
SECTION 2: ABOUT YOUR SITUATION
Myself (I have Parkinson's)
My spouse/partner
My parent
My relative
A friend
Other
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6
How long since Parkinson's diagnosis?
SECTION 2: ABOUT YOUR SITUATION
Less than 1 year
1-3 years
4-7 years
8-10 years
More than 10 years
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7
Does the person with Parkinson's experience "Freezing of Gait" (feet feel stuck to the floor)
SECTION 2: ABOUT YOUR SITUATION
Never/Rarely
Occasionally (1-2 times per week)
Frequently (3-5 times per week)
Daily
Multiple times daily
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8
Has there been a fall in the past 6 months?
SECTION 3: FALL HISTORY & MOBILITY
No falls
One fall
2-3 falls
4 or more falls
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9
Have there been any "near-miss" incidents (catching themselves, stumbling)?
SECTION 3: FALL HISTORY & MOBILITY
Never
Rarely (less than once per month)
Sometimes (1-3 times per month)
Often (weekly)
Very Frequently (multiple times per week)
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10
Current mobility status:
SECTION 3: FALL HISTORY & MOBILITY
Walks independently without aids
Uses a cane/walking stick
Uses a standard walker/rollator
Uses a wheelchair occasionally
Uses a wheelchair full-time
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11
What type of home?
SECTION 4: HOME ENVIRONMENT
Single-story (bungalow/ground floor apartment)
Two-story house
Three or more stories
Apartment with elevator access
Other
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12
Are stairs required for daily activities (bedroom, bathroom, kitchen)?
SECTION 4: HOME ENVIRONMENT
No stairs needed
Stairs rarely used
Stairs used daily
Stairs used multiple times daily
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13
Bathroom situation
SECTION 4: HOME ENVIRONMENT
Walk-in/level-access shower
Shower with low threshold
Standard bathtub with overhead shower
High-sided bathtub only
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14
Are grab rails installed in the bathroom?
SECTION 4: HOME ENVIRONMENT
Yes, HSE-compliant grab rails installed
Yes, but unsure if properly installed
No, but planned/needed
No, not yet considered
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15
Flooring type in main walking areas
SECTION 4: HOME ENVIRONMENT
Solid, matte flooring (wood/tile)
Carpeting (solid color)
Patterned carpets/rugs
High-contrast flooring transitions
Shiny/glossy surfaces
Loose rugs/mats
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16
Hallway and doorway width
SECTION 4: HOME ENVIRONMENT
Wide, easy to navigate
Adequate but tight in places
Narrow, requires careful maneuvering
Very narrow, furniture often bumped
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17
Bed height (when sitting on edge, are feet flat on floor with knees at 90°)?
SECTION 5: BEDROOM & NIGHTTIME SAFETY
Perfect height
Slightly too low
Too low (difficult to stand)
Too high (feet don't reach floor)
Unsure
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18
Path from bed to bathroom at night
SECTION 5: BEDROOM & NIGHTTIME SAFETY
Clear, straight path with night lighting
Clear path, no lighting
Some obstacles, furniture to navigate around
Tight turns or stairs required
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19
What safety modifications have already been made?
SECTION 6: CURRENT ADAPTATIONS & SUPPORT
Grab rails installed
Raised toilet seat
Stairlift or home elevator
Downstairs bedroom created
Level-access shower
Improved lighting throughout
Motion-sensor lights
Removed loose rugs
Simplified flooring (removed patterns)
None yet
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20
Has an Occupational Therapist assessed the home?
SECTION 6: CURRENT ADAPTATIONS & SUPPORT
Yes, recommendations received and implemented
Yes, recommendations received but not yet implemented
Assessment scheduled
No, but planning to request one
No, haven't considered it yet
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21
Is caregiver support currently in place?
SECTION 6: CURRENT ADAPTATIONS & SUPPORT
Full-time family caregiver present
Part-time caregiver/family support
Professional home care visits
No regular caregiver support currently
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22
What are your biggest safety concerns right now?
SECTION 7: PRIORITY CONCERNS
Falling in the bathroom
Navigating stairs
Freezing episodes in doorways
Getting in/out of bed safely
Nighttime bathroom trips
Walking outdoors/uneven surfaces
Getting up from chairs/toilet
Maintaining independence as long as possible
Caregiver struggling to assist safely
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23
Are you currently considering any of the following?
SECTION 7: PRIORITY CONCERNS
Mobility aids (rollator, wheelchair)
Home modifications (bathroom, bedroom, stairlift)
Applying for HSE grants
Moving to single-story accommodation
Residential care options
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24
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