Home Safety Modification Form

Referred By
Client Information
Gender
Marital Status
Care Giver's Information
Screening Questions
Does the client live alone?
Are there any pets in the home?
Is the client a veteran?
Does the client own or rent the home?
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Does the client receive CalFresh support?
Insurance Type
Referred to Care Management?
Is the client English speaking?
If no, is there an interpreter available?
Race/Ethnicity
History of Falls
Has the client had a fall?
Was 911 called after the fall?
Did the call result in ambulance ride/hospital admission?
Exercise
Is the client exercising?
Interest in in-home exercise program?
Client Care
Other fall prevention programs available to client