Lumiform
Features Solutions Resources Templates Enterprise Pricing
Select a language
Englishen
Deutschde
Françaisfr
Españoles
Português (BR)pt-BR
en
Contact salesLog in
Sign up
Back
Englishen
Deutschde
Françaisfr
Españoles
Português (BR)pt-BR
Features Solutions Resources Templates Enterprise Pricing
Free demo
Log in
en
Book a personal demoView video demoContact sales
Explore
Resource hubCentral repository for all Lumiform resourcesCustomer storiesReal-world successes and experiences with Lumiform.
Learn
Template collectionsComprehensive collections of best practice templates.Topic guidesComprehensive safety, quality, and excellence insights.LexiconDefinitions key to quality, safety, and compliance.
Support
Developer's guideTechnical documentation for developers.Help centerAssistance with onboarding and platform mastery.
Featured reads
Explore our collection of 38 free preventive maintenance checklists

Template collection

Explore our collection of 38 free preventive maintenance checklists

Start reading
Your guide to performing and documenting efficient child care observation

Topic guide

Your guide to performing and documenting efficient child care observation

Start reading
Lumiform as customer journey mapping tool in gastronomy

Success story

Lumiform as customer journey mapping tool in gastronomy

Start reading
Book a personal demoView video demoContact sales
By industry
Food and hospitalityManufacturingConstructionRetailTransport and logisticsFacility managementView all industries
By business needs
Health and safety managementQuality managementOperational excellenceRisk management and complianceView all business needs
By use case
Safety management softwareEnergy audit appForklift inspection appBuilding management softwareVehicle inspection appQMS appKaizen method appProperty inspection appRestaurant inspection appElevator management appProject management softwareFire inspection app
View all app uses
Book a personal demoView video demoContact sales
Overview
Template libraryDiscover over 12,000 free, ready-made and expert proofed templates.
Use cases
CleaningMaintenanceRisk assessmentSupply chainIncident management
Business needs
Health and safety managementQuality managementOperational excellenceRisk management and compliance
Industries
Food and hospitalityManufacturingRetailTransport and logisticsConstructionFacility management
Book a personal demoView video demoContact sales
Overview
Product overviewAll features
Capabilities
Digitize
Form builderMobile AppActions
Automate
Workflow automationApprovalsIntegrations
Transparency and accountability
ReportsAnalytics
Orchestrate
Administration
Book a personal demoView video demoContact sales
Templates
Home visit safety checklist template

Home visit safety checklist template

Use this template to assess the health status of a patient during a home visit.

Use this template
or download pdf
Home visit safety checklist template

Use this template to assess the health status of a patient during a home visit.

Use this template
or download pdf

About the Home visit safety checklist template

Home visit checklists are used by healthcare professionals when conducting house calls to assess the medical condition of patients and provide patient care. This digital home visit checklist covers the patient’s immobility, nutrition, home environment, other people, medications, examination, safety, spiritual health, and other services needed (INHOMESSS).
A home visit checklist is a document that contains information about the patient, such as their medical history and current condition. It is also used to track the patient's progress and provide care during their visits. The purpose of a home visit checklist is to ensure quality patient care by reducing paperwork and improving communication between doctors and patients. By having everything documented in one place, it becomes easy for both parties to understand the patient's health status and make appropriate decisions based on that information.

Related categories

  • Quality management templates
  • Health care templates
  • Incident management templates
  • Quality assurance templates
Preview of the template
Home Visit
Impairments/immobility
Any indication of cognitive impairment?
Advanced activities of daily living (select all that apply)
Specify other
Activities of daily living (select all that apply)
Any issues with balance and gait (select all that apply)
Sensory impairments (select all that apply)
Falls?
Nutrition
Eating habits
Variety and quality of food
Pantry
Refrigerator
Freezer
Nutritional status
Obesity
Malnutrition
Other
Fluid intake
Alcohol presence/use
Swallowing difficulty
Oral health
Home Environment
Neighborhood
Exterior of home
Interior of home (select all that apply)
Other people
Is there a caregiver?
Who?
Tasks of the caregiver
Hours of caregiving per day
Stress?
Coping?
Abuse?
Need for respite?
Physically or emotionally capable?
Social supports?
Advanced directives?
Power of attorney?
Who?
Financial resources
Patient attitude
Medications
Prescription drugs
Nonprescription drugs
Dietary supplements
Medications organized
Medication compliance
Medication discrepancy
Multiple prescribers
Allergies to medications
Written instructions
Examination
Weight
Weight loss?
Height
Blood pressure
Glucose
Urinalysis
Other
Mini-Mental State Examination
Depression screening
General physical condition
Focused examination
Safety
Access to emergency services
Alternative power source if needed
Adaptations to home needed
Telephone availability
Bathroom
Kitchen
Carpets
Lighting
Electrical cords
Stairs
Tables, chairs, and other furniture
Hot water heater
Fire and smoke detectors
Fire extinguishers
Emergency plans
Evacuation route
Gas or electric range
Heating/air-conditioning
Water source
Spiritual health
Spiritual includes cultural and ethnic influences
Services
e.g. fire, police, emergency medical services, home health, social services, meals on wheels, hospice, transportation, legal, equipment, health benefit advisor
Completion
Comments/Recommendations
Conducted by: Name & Signature
This template was downloaded 698 times

More templates like this

Infection Control Surveillance
Infection Control Surveillance
Benefit from using an infection control surveillance checklist to reveal unhygienic practices that may be compromising your patients. Once you uncover problem areas, you can introduce corrective actions to mitigate the risk of contracting an illness.
Safety templates
Joint Commission Mock Survey Tool
Joint Commission Mock Survey Tool
Utilize this joint commission mock survey template as a tool to help diagnose problem areas within your organization to improve patient care.
Quality assurance templates
Medical Record Audit
Medical Record Audit
Record data and the information after the auditor completes the medical record audit with this checklist.
Templates for business processes

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.
Lumiform logo
Platform
HomeSign upProductAll featuresPricingEnterpriseTrust and securityCustomer success offeringsDownload the app
Solutions
IndustriesFood and hospitalityManufacturingConstructionRetailTransport and logisticsFacility management
Business needsHealth and safety managementQuality managementOperational excellenceCompliance and risk management
Uses cases
Learn
Template collectionsTopic guidesLexiconHelp centerJournalInfographicsVideos
Resources
Lumiform templatesby industryby use caseby business needAll categories
Customer storiesDeveloper APIResource hubIntegrations
Company
AboutJobsLegalBook a demoContact sales
© 2025 LumiformTerms and conditionsPrivacyData processingSitemap
App StoreGoogle play