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Medical
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Do you or any member of your household consider youself to be disabled?
Yes
No
Are you or any member if your household registered as disabled?
Yes
No
Do you, or any member of your household, have any health/disability reasons for wishing to be re-housed?
Yes
No
Please provide details
Please give details of person for whom medical points are being sought:
Describe in your own words what health problems or disability you have:
Do you have difficulty walking?
Yes
No
Some difficulty
Do you use any of these to help you get around
Crutches
Walking stick
Walking frame
Other
Please state
Do you use a wheelchair
Yes
No
Do you use it:
Indoors
Outdoors
Both indoor and Outdoors
Is your current home Wheelchair adapted?
Yes
No
Would a wheelchair be used inside your home, if your home was suitable?
Yes
No
Do you have difficulty with stairs inside and outside your home?
Yes
No
Some difficulty
How many stairs are there to your front door
How many stairs are there to your back door
How do you manage these stairs?
Have no problem with stairs
Can mange with difficulty
Need help to manage stairs
Cannot manage stairs at all
Do you have internal stairs?
Yes
No
How many?
How do you manage these stairs?
Have no problem with stairs
Can mange with difficulty
Need help to manage stairs
Cannot manage stairs at all
Do you reach any of the following rooms by using internal stairs?
Bedroom
Yes
No
Bathroom
Yes
No
Only Toilet
Yes
No
Have there been any adaptations made to your house?
Yes
No
Please describe adaptations
Do you need further adaptions to your existing home?
Yes
No
Please describe adaptations required
Do you require adaptations to any property offered by the Association?
Yes
No
Please describe adaptations required
What type of heating do you have?
Gas Central heating
Electric storage heaters
no central heating
what type of heating would you prefer?
Does your current heating cause you health problems?
Yes
No
Please describe how
Does your current heating cause you health problems?
Yes
No
Please tell us why
If your health problem is not covered by any of the questions above, please tell us how your housing affects your illness or disability, and how you feel a move would help
Please give name and address of your GP and that of any other health care professional with whom you have had recent contact. We may need to contact them
G.P's name
Address
Telephone No
Other medical professional name
Other medical professional address
Other medical professional telephone No
Do we have permission to contact any of the above people if we need more information about your health
Yes
No
Do any members of your household (moving with you) currently share a bedroom?
Yes
No
Please tell us who?
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