Medical Assessment form Medical Assessment Form Please complete this form if you need us to consider: an illness or disability your support needs what you need to help you live independently or your need for a special type of housing (for example, sheltered housing) If there is more than one person applying for housing because of their health needs, each of them should fill in a separate medical assessment form.Name* First Last Date of Birth* Address Address Line 1 Address Line 2 Town/City County Postcode Do you consider yourself to be disabled?YesNoPlease tick any of the following that apply to you I have difficulty with my eyesight I have difficulty hearing I am registered blind I am profoundly deaf or communicate using British Sign Language or lip read About your homeType of homeFlatMaisonetteBungalowHouseIf it is a flat/maisonette, what level is it on?Is a lift available?YesNoPlease tell us what health problems you haveWould you prefer to stay in your own home if you could?YesNoWhat adaptations, if any, have been made to help you get around or remain in your home?Why is your current home not suitable for your health needs?Getting Around Your HomeDo you have any difficulty walking?NoSome difficultyYesDo you use any of these to help you get around? Walking stick Walking frame Wheelchair Do you use a wheelchair indoors or outdoors?Indoors onlyOutdoors onlyBothStairsDo you have any difficulty with stairs inside or outside your home?YesNoPlease tell us what problems you have with stairsDo you have to go upstairs to the: Toilet Bathroom Bedroom Please indicate how many individual steps there are in total.Inside your houseOutside your houseAre there handrails on the stair(s)?YesNoAre they on one side or both sides?One sideBoth sidesHow many individual steps would you be able to manage easily?Do you already have, or do you need, any equipment to help you with the stairs?YesNoPlease describe the equipmentBathroomWhat does your bathroom have? A bath A shower over the bath A separate shower unit A wet floor area Do you have any difficulty using the bath, shower or toilet?YesNoPlease tell us about itHeatingWhat type of heating do you have e.g. gas fired central heating with radiators; gas fires; warm air central heating?Do you have a medical need for a particular type of heating?YesNoPlease tell us the type required and reasons for thisIf you have any comments on heating or ventilation in your home, please note them hereDampnessDoes your home have any dampness?YesNoIf this affects your health, please tell us about it.BedrooomDoes your illness or disability mean you need an extra bedroom?YesNoPlease tell us why you need thisShops and TransportDo you go to the shops alone?YesNoHow do you get there? Walk Car Bus Taxi Do you have any difficulty getting to the shops and other places?YesNoPlease tell us what difficulties these areOther Health ProblemsIf 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 mov e would help.HospitalDo you regularly attend a hospital or clinic?YesNoWhich hospital/clinic?What is your consultant’s name?Family DoctorWhat is your Doctor's name and address?If you get regular support from anyone else, such as District Nurse or Occupational Therapist, please give their name and address if possible.Getting Further InformationOn occasion it may be necessary to seek expert opinion from a Community Medicine Specialist, in which case details would be passed to him/her for consideration. We might also need to ask your hospital consultant, family doctor, district nurse or occupational therapist or other health professional for further information.Do we have your permission to contact these people if we need more information about your health?YesNoResponsibility for any charges made by health professionals in connection with an application for housing rests with the applicant and not with Cairn.Please sign your name hereDate NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.