Protocol 4-916-50 - Physical Environment Assessment Tool

CMH EMS & MIH Protocols

Date:

Name of person completing this form:

Patient sticker here
Dwelling Check MULTIPLE Points possible Points given
Enclosed shelter. 2
Electricity. 2
Running water. 2
Safe temperature. 2
Cleanliness Check ONLY ONE Points possible Points given
Immaculate. 4
Clutter. 3
Small biological waste. 2
Large biological waste. 1
Social Structure Check ONLY ONE Points possible Points given
Lives with other(s). 12
Lives alone. 9
Verbal abuse/neglect. 6
Physical abuse/neglect. 3
Hazards Check ONLY ONE Points possible Points given
None. 12
Possible. 9
Probable. 6
Certain. 3

Select the environmental assessment based on points and table below:

Assessment Minimum score required
Healthy 32
Less than optimal 28
Referral assistance 17
Urgent intervention 7

Citations:

Change Log:

DateLink to
previous
version		Description of change
05/26/23Created this tool.

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