Issue link: https://blog.providence.org/i/1256336
14 Pre-SURGERY home safety assessment Safety is our biggest priority as you may be at an increased risk to fall during your recovery after surgery. To reduce the risk of falling, please complete the following : Where to do you plan to recover after discharge? Please circle: Home Apartment Condo Will you live alone? Yes / No If no: Who will be with you after surgery? Name: ___________________________________ Relationship: ______________ Will you have help at home? Yes / No How many hours of help during the day? _____ How many hours during the night? _____ Are there stairs inside the house? Yes / No If yes: How many stairs are there? _____ Is there a rail to hold on to? Yes / No Are there stairs / steps to enter the house? Yes / No If yes: How many? _____ Is there a rail to hold on to? Yes / No Are there any concerns about the house? Please circle: Narrow Hallway Bathroom access issues Other: ____________________________________ Do you have any of the following? Please circle: Reacher Sock Aid Long Sponge / Brush Long Shoehorn Stationary Bike Do you have a handrail in the shower or tub? Yes / No Does your bathroom have any of the following? Please circle: Tub Shower Shower Curtain Shower Stall Glass Door Do you have any of the following bathroom equipment? Please circle: Tub Bench Raised Toilet Raised Toilet Seat Grab Bar Toilet Height: ________________ Do you have any of the following equipment? Please circle: Walker Wheelchair Crutches Cane Do you currently use any assistive equipment to walk? Please explain: _________________________________________________________________________________ Recently, how far can you walk? Please circle: Only in the house A couple of blocks In the Community Unlimited Distance I do not walk Which daily activities can you perform independently? Please circle: Grooming Hygiene Toileting Bathing Dressing Bed height in inches: _________________ Number of stairs to go to the bedroom: ______________ When lying in your bed, which side do you get out of bed? Left Right How many times on average do you get out of bed at night? ___________ What is the distance from your bed to the bathroom? ________________ Do you have any animals at home? Yes / No If yes, did you make plans for someone to care for your pet? _______________________________ Do you have any other medical conditions or surgeries that would affect your rehabilitation and healing? If yes please explain________________________________________________________