Dementia Patient Door Security Assessment Form

Dementia Patient Door Security Assessment Form
Use this form to evaluate and document the security needs and potential risks related to doors for individuals living with dementia.
Type of residence
Other
Number of exterior doors in the residence
Current security features present on main doors (select all that apply)
Other
How often does the individual attempt to open or exit through exterior doors?
Level of risk for unsupervised exit through doors
How easy are the door locks and security features for caregivers to operate?
Assessment of each exterior door
Rows Condition Visibility from main living area Accessibility by patient
Front door
Back door
Garage door
Are there any recent incidents or close calls involving doors?
Overall security level of all exterior doors

1
2
3
4
5
1 is Very Poor, 5 is Excellent
Recommendations or notes regarding door security (optional)
Should be Empty:

Select theme:

Rows	Condition	Visibility from main living area	Accessibility by patient
Front door
Back door
Garage door