Are You or A Loved One Safe to Live Home Alone?

Are You or a Loved One Safe to Live Home Alone?

If you have family members, loved ones or friends who are living at home and may be experiencing a decline in their memory or mental abilities, you can use the following questionnaire to help determine their risk for accidents.

Living Environment

1.            a)             This person lives on her/his own. Yes [ 1 ] No [ 0 ]                                    _____

b)             This person is alone at home

Always [ 4 ]  Most of the time [ 3 ] Occasionally [ 2 ]  Never [ 1 ]                        _____

Smoking

2.             This person leaves cigarette burn marks on the floor, furniture or clothing.

Yes [ 1 ]  No [ 0 ]                                                                                                _____

Fire and Burns

3.             a)             The stove on/off buttons are located . . .

On the front of the stove [ 1 ]  on the top of the stove [ 2 ]

Behind the hotplates [ 3 ]                                                                        _____

b)             This person is capable of turning on the stove him/herself

Yes [ 1 ]  No [ 0 ]  Doesn’t know [ 1 ]                                                            ______

c)            This person cooks his/her own food.

Always [ 4 ]  Most of the time [ 3 ]  Occasionally [ 2 ]  Never [ 1 ]             _____

d)            This person forgets a pan on the stove.

Always [ 4 ]  Most of the time [ 3 ]  Occasionally [ 2 ]  Never [ 1 ]             _____

e)            The heating system uses . . .

electricity [ 1 ]   natural gas [ 2 ]                                                            _____

Nutrition

4.            a)            This person receives meals-on-wheels or other prepared meals.

2 to 6 times a week [ 3 ]  once or less a week [ 4 ]                                    _____

b)            This person’s meals contain food from different food groups.

Always [ 1 ]  Most of the time [ 2 ]  Occasionally [ 3 ]  Never [ 4 ]            _____

Food Poisoning and Toxic Substances

5.            This person can tell the difference between food that is fresh and food that

is spoiled.            Yes [ 0 ]  No [ 1 ]                                                                        _____

Medication and Health Problems

6.            a)            This person takes on a regular basis . . .

1 to 3 prescribed medications [ 2 ]  4 to 6 medications [ 3 ]

7 medications or more [ 4 ]  Does not take any medication [ 1 ]                        _____

b)             This person takes medication to help him/her sleep or relax

Yes [ 1 ]  No [ 0 ]                                                                                    _____

c)            Does this person suffer from any physical health problems?

None [ 1 ]  Minor [ 2 ]  Moderate [ 3 ]  Severe [ 4 ]                                    _____

d)            This person accepts treatment for his/her physical health problems.

Yes [ 0 ]  No [ 1 ]  Does not apply [ 0 ]                                                             _____

e)            Does this person dress appropriately according to the

changing temperature, both indoors and outdoors?

Yes [ 0 ]  No [1 ]                                                                                    _____

Wandering

7.            a)            This person gets lost in familiar surroundings.

Very often [ 4 ]  Often [ 3 ]  Sometimes [ 2 ]  Never [ 1 ]                                    _____

b)            Has this person every gotten lost?

Yes [ 1 ]  No [ 0 ]                                                                                    _____

c)            Can this person find his/her way home?

Yes [ 0 ]  No [ 1 ]                                                                                    _____

SCORE            Maximum (43)            _____

The closer the score is to the maximum of 43,

the greater the risk.