Living setting Lives at home alone Home with family or regular helpers Home with paid care Assisted living, memory care, or facility
Memory or dementia stage New or early memory changes Changing judgment, routines, or supervision needs High support needs Not sure
Recent safety trigger No recent incident known Near miss or caregiver concern Fall, burn, medication, or poisoning concern Wandering, exit, or getting-lost concern Caregiver says the home feels harder to manage
Kitchen safety status Needs review Still cooks alone Recent cooking, appliance, food, or burn concern Mostly supervised or meals prepared
Bathroom safety status Needs review Falls, slipping, or transfer risk Bathing or toileting needs helper review Recently reviewed
Exits and outside access Not reviewed yet Some exit or outside access concern High exit, wandering, stairs, balcony, or car-key risk Reviewed recently
Medicines and chemicals Not secured yet Some items secured Secure routine in place Not sure
Tools, weapons, and garage hazards Not reviewed yet Tools, chemicals, ladders, fuel, or equipment present Weapons or firearms may be present Reviewed and secured
Nighttime safety Needs review Night walking, exits, or bathroom trips Sleep disruption or sundowning concern Stable nighttime routine
Caregiver review pattern Mostly one helper notices safety issues Several family or paid helpers Helpers disagree about what needs changing Written review routine exists
Clinician or local support Not started yet Clinician or home-safety visit scheduled Clinician, therapy, social work, or local support active Not sure who to ask
Use this to prepare a privacy-safe home walkthrough.
Do not enter names, addresses, diagnoses, medication names, exact alarm locations, key locations, account numbers, Medicare numbers, Social Security numbers, or private medical details. Keep real care notes and emergency plans in a secure folder shared only with trusted helpers.
This planner is educational and organizational only. It is not medical, legal, emergency-response, housing, insurance, benefits, dementia-care, or home-modification advice. For immediate danger, fire, gas smell, carbon-monoxide alarm, suspected poisoning, a missing person, weapon risk, violence, unsafe driving, or a medical emergency, contact emergency services or the care team right away.
Useful references:
NIA Alzheimer's home safety tips ,
Alzheimer's Association home safety tips ,
CDC STEADI caregiver resources ,
Medicare cognitive assessment care planning ,
Eldercare Locator .
