CONDITION

YES

NO

Do you have dim lighting throughout your home?

Do you have lighting in your hallways and stairwells?

Do you have throw rugs in your home that slide?

Are there raised carpet edges in areas of your home?

Do you wax the floors?

Are there extension or appliance cords in the walking pathway?

Are there objects lying on the floor or stairs?

Do you have railings on both sides of the stairs inside and outside?

Do you have problems differentiating between steps?

Are items put in places where you cannot reach?

Do you have to reach or bend excessively to obtain items?

Are there heavy items on the top shelves?

Do you have difficulty getting into and out of the bathtub or shower?

Do you have trouble standing while you are in the shower?

Is the toilet seat too low?

Are there cracks in the pavement or walkways?

Other?