OXYGEN RISK ASSESSMENT FORM

PATIENT NAME	DATE
PATIENT DETAILS

NOTE: Risk should be assessed on a continuous basis, and every home oxygen prescription must be reviewed and followed up on regularly with respiratory specialists. Please attach supporting documentation, if available.

RISK ASSESSMENT

Yes	No	CATEGORY / RISK	NOTES
PHYSICAL RISKS
Mobility and/or balance challenges
Vision impairment
Cognitive impairment
Living conditions (e.g. clutter, stair lift)
Other:
Other:
LIFESTYLE RISKS
Current smoker – If yes, list types of products patient smokes, and if visible evidence exists (burns on skin, furniture, etc.)
In process of quitting smoking – If yes, what is the patient’s progress? Is the patient using a tool or program? How was this confirmed? (e.g. CO monitor levels)
Ex-Smoker – If yes, for how long? How was this confirmed? (e.g. home visit, CO monitor levels)
Other smoker(s) on premises
Addiction (e.g. alcohol, drugs)
Other:
Other:

RISK ASSESSMENT continued

Yes	No	CATEGORY / RISK	NOTES
ENVIRONMENTAL RISKS
Lives in building with multiple occupancy
Lives unaccompanied
Lives with vulnerable dependents (e.g. elderly, children)
Cooks with gas stove
Wheelchair dependent
Bedbound
Working smoke alarms
Oxygen equipment storage concerns
Other:
Other:

ADDITIONAL INFORMATION

DECISION

NAME AND ROLE OF RISK ASSESSOR	NAME AND ROLE OF APPROVING OFFICIAL
LOCATION	LOCATION
SIGNATURE	DATE	SIGNATURE	DATE

DISCLAIMER Any articles, templates, or information provided by Smartsheet on the website are for reference only. While we strive to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability, or availability with respect to the website or the information, articles, templates, or related graphics contained on the website. Any reliance you place on such information is therefore strictly at your own risk.