Home Assessment:

To be completed before discharge to home

Performed by: Interview or Physical Home Assessment

Name of Person Performed Assessment: ______Date: ______

Acceptable / Date Assessed / Action Plan / Date Completed
Electrical Safety
Home has electricity / c Yes
c No
There is at least one grounded electrical outlet in the patient’s bedroom not connected to a switch / c Yes
c No
Outlets in the home are properly grounded / c Yes
c No
Household Safety
Overall condition of the house is good. / c Yes
c No
Home has running water / c Yes
c No
Stairs are secure and in good shape / c Yes
c No

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Acceptable / Date Assessed / Action Plan / Date Completed
Household Safety
Furniture is arranged for good traffic flow / c Yes
c No
Home has adequate lighting throughout / c Yes
c No
Restrooms are easily accessible / c Yes
c No
Entrances to the home are clear and stable / c Yes
c No
Patient has access to a phone in an emergency / c Yes
c No
Emergency phone numbers easily located / c Yes
c No
Falls Safety
Showering facilities are equipped with a non-skid surface / c Yes
c No
All rugs are secure or have been removed / c Yes
c No
Floors and hallways are free of clutter and possible hazards / c Yes
c No

This Home Assessment Form has been provided by HeartWare for general informational purposes. The Form is intended to be used to facilitate discussions between healthcare professionals, patients and caregivers. The list of items on the Form is not intended to be an exhaustive list, and some of the items require the person completing the form to exercise his or her subjective judgment. The Form is not intended to constitute medical advice, nor should it be used as a replacement for the advice, treatment or diagnosis of a licensed physician. If you have questions related to the Form, you may contact your HeartWare representative. In addition, HeartWare Clinical Support is available via the Emergency Hotline (888.494.6365). This Hotline resource is available 24 hours a day, 7 days a week, 365 days a year.

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