Client Home Risk Assessment

Does the client have equipment in their home?*
- Yes
- No
Detail all equipment in client's home
Equipment Checked Date Due Maintenance on

enter each equipment item in the text box above - then click the plus button to add more.
Is the equipment maintained and checked?*
- Yes
- No
3. Client Movement Assessment/Mobility Assessment
detail below the movement of the client and whether its Unaided or with an aid? What Aid /Equipment? With Supervision? With support 1 or 2 persons?
Movement - Walking*
Movement - Washing*
Movement - Chair to standing*
Movement - Transfers Chair to bed, Bed to chair, Chair to toilet/commode*
Movement - Bed to standing*
Movement - Rolling bed*
Movement - Positioning in bed*
Movement - Wheelchair Transfers*
Client Name
First Last
Clients Signature*
please draw your signature like you would on a piece of paper in the box above. If client unable to sign please put an X above as the person completing the form.
Senior's Name*
First Last
Senior Carer Completing Form Signature:*
please draw your signature like you would on a piece of paper in the box above.

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Office Details:

Equipment	Checked Date	Due Maintenance on