Home Visit Checklist

Complete this form to organise a home visit

Please complete this form

Are you the client Mouthworks will visit at home?

Yes

No, I'm filling in this form on their behalf

Your Name

Client's Name

Client's Surname

Enter the address for your home visit.

Street Address

City

State

Postcode

This information will help us prepare for our visit to your home.

Getting to Your Address

	Yes	No
Is the street sign visible?
Is there difficulty finding the property or the number?
Is the gate difficult to open?
Are there any dangerous or slippery steps?
Is the client able to open the door?
Is there mobile reception?

Which door is used for entry?

Front Door

Back Door

Side Door

Tell us about any other hazards (if applicable)

Health

	Yes	No
Are there any known infectious illnesses in the house? (gastro, measles etc)
Has you or anyone in the house returned from overseas or interstate in the last 14 days?
Have you or anyone in your home had any contact with a current or suspected case of COVID-19 (Coronavirus)?

The Occupants

	Yes	No
Does the client have any pets/animals around the house?
Does the client or do other occupants smoke?
Have communication methods with the client been established?
Are there any other occupants or visitors likely to be presents during home visits?
Is there known substance abuse amongst the occupants or the visitors?
Does the client, or other occupants have a history of violent or aggressive behaviour?

Is there any extra information you think we should know about making a home visit?

I have read and agree to the Mouthworks Terms and Conditions and Privacy Policy

Hobart:

Suite 7/32 Bayfield Street
Rosny TAS, Australia

Launceston:

1a 75 Patterson Street
Launceston TAS, Australia

Handy Links:

Our Online Forms:

Office Hours:

Day	hours
Mon - Wed	8am - 6pm
Thur & Fri	8am - 5pm

Top

	Yes	No
Is there adequate lighting?
Are there any trip or clip hazards?
Are smoke detectors present and maintained?
Are there any known weapons or firearms in the house?