Medical Assessment Form
Name of person
who is ill/disabled
Address
Reg. No.
www.home4u.org.uk
CONFIDENTIAL
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.
ABOUT YOU
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
Present accommodation
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
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Full name Relationship to you Date of birth
July 2018 Medical Assessment Form 3
Because of these health condition(s), why is the property you now live in not suitable?
How would your condition(s) improve if you moved to a suitable property?
What sort of accommodation do you need?
Would you need any alterations if we could offer you somewhere else to live
Eg bath rails? If yes, please list the alterations.Please supply a copy of your occupational
therapist's report detailing the adaptations needed.
Yes No
Do you get any help or are awaiting support from people like: (please tick the box(es) that
apply to you)
District nurse Occupational Therapist or similar Home Help Meals on Wheels
Mental Health Team Community Psychiatric Nurse Learning Disabilities Team
Other No support
List how often
If so, please give us their name(s) and address(es): Complete on a separate sheet if necessary
Please describe the health problem or disability that affects you now
How long have you been affected by the health condition(s)/disability?
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Please tell us what medication you take and the dose:
YOU MUST ENCLOSE A PHOTOCOPY if you are on medication, of the repeat prescription slip for this
form to be considered.
Medicine:
Dose: How many times a day do you take this?
How long have you been taking this?
Medicine:
Dose: How many times a day do you take this?
How long have you been taking this?
Medicine:
Dose: How many times a day do you take this?
How long have you been taking this?
Medicine:
Dose: How many times a day do you take this?
How long have you been taking this?
TREATMENT
Are you receiving any treatment for a condition?
(e.g. Chemotherapy, Physiotherapy, Psychotherapy, Radiotherapy) Yes No
If yes, which, providing details of how long you have been receiving this treatment
Your doctor’s name and address:
Your doctor’s telephone number:
Date last seen and outcome:
If you have a consultant, please give their name(s) and hospital address:
Which medical condition are you seeing the consultant for?
Your consultant’s telephone number:
Date last seen and outcome:
ABOUT THE HOME YOU LIVE IN NOW
Do you have difficulty using stairs?
Yes No
Do you have to climb stairs or steps to your front door? Yes No
Is your home all on one level once you are inside? Yes No
Have any alterations been made to your home Yes No
because of a medical problem or disability?
If so give details below:
Are you registered disabled? Yes No
If yes, please provide evidence of registration
Do you use a wheelchair? Yes No
If yes, do you use it – Inside outside both
Do you use a Walking Frame? Yes No
If yes, do you use it – Inside outside both
Do you use a Walking Stick? Yes No
If yes, do you use it – Inside outside both
Can you bathe, wash and dress yourself without help? Yes No
If no, who helps you?
Can you do your shopping without help? Yes No
If no, who helps you?
Can you do your housework without help? Yes No
If no, who helps you?
Do you require assistance at night?
Yes No
Please provide details and evidence of this:
July 2018 Medical Assessment Form 5
On a
waiting list
How many?
rgw
Are you receiving Disablement Benefits? (eg Employment and Support Allowance (ESA),
Disability Living Allowance (DLA), Attendance Allowance (AA), Personal Independent
Payment (PIP), Industrial Injury Payment).
Yes No
If yes to DLA, which level applies to you?
Mobility: High Low
Care: High Medium Low
Please attach a photocopy of your DLA entitlement letter showing the benefit you receive.
Please use this space to provide any other information you want to give us about your
medical condition or disability:
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If yes, please specify
including date it
awarded and provide
evidence of this.
DECLARATION
I / We have checked the details written on this form and declare that it is true and complete in every detail.
I / We understand that the Partner may pass this information to any Housing Association to which I may
be nominated.
I / We give my permission for this information to be checked by contacting persons as reasonably
considered prudent by the partners such as the DWP, Social Services, Employment Service, bank,
building society, estate agent, solicitor, landlord, Immigration Service, doctor, employer, Housing
Associations, Councils.
I / We understand that the information I have given is confidential and can only be used in ways allowed
by the Date Protection Act. I / We understand that you may share this information with other organisations
to prevent and detect fraud.
I / We will tell the partner if there is any change in my / our circumstances.
I / We understand that if I have given information which is not true, I may be
prosecuted and that I / we may be evicted from any property which I / we may have been given.
I authorise the release of any information, which may be relevant to my housing application or to my
medical condition, held by other agencies/individuals,to North Herts Housing Partnership. NHHP will not
be responsible for any fees or costs in obtaining information.
Signed:
Date: / /
Has someone helped you complete this form? Yes No
If yes, please provide their details below
Name:
Address:
Contact details:
Relationship:
Please note it may take up to six weeks to receive confirmation of your
medical assessment.
July 2018 Medical Assessment Form 7
H24-07-18
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