Please use this form if you want or need to move and you or someone you are living with has a long term
illness or disability. All the information will be treated as confidential.
Please try to give as much detail as possible as this will help us to help you.
If more than one person included in your application has a long term medical problem or disability
that affects their housing, please complete a separate form for each person.
If you need help in completing the form, please ask, we will be happy to help.
Name of the person who is ill or disabled:
If this is a child, what is the surname of the parent?
Date of Birth: / / Male Female
Do you have your own bedroom? Yes No
If no, who do you share with? Give relationship and age of other person(s)
Please tell us about all the people who live permanently in your home
House Flat Maisonette Bungalow Room in shared house
Other Please give details Please No. of Bedrooms within property
Floor level of flat / maisonette: ground 1st 2nd 3rd 4th or above
Is there a lift? Yes No
Is your heating Gas Electric Other None
How is the heat provided?
(For example, radiators, storage heaters, gas fire and so on).
Which rooms are heated? Bedrooms Living Rooms Bathoom Kitchen
Is your bathroom upstairs downstairs
Is your toilet upstairs downstairs both
2 Medical Assessment Form July 2018
Full name Relationship to you Date of birth