Medical Priority Application Form

Medical Assessment Form

To be completed if you (or anyone moving with you) suffers from any illness or disability which is adversely affected by your current accommodation.

PLEASE NOTE THIS FORM IS SUPPLEMENTARY TO THE HOUSING APPLICATION FORM. WE CANNOT PROCESS THIS FORM WITHOUT A COMPLETED HOUSING APPLICATION FORM.

Question Title

* Main Applicant

Name

Email Address

Address 1

Post Code

NI Number of Main Appicant

Question Title

* Name of Person Affected

Medical Conditions
Please list all medical conditions, the medication you take and describe how your current accommodation affects each condition. (If you can, please provide a copy of your request prescription)

Question Title

* Medical Condition

Condition

Medication

How would moving home improve this condition?

Question Title

* Medical Condition

Condition

Medication

How would moving home improve this condition?

Question Title

* Medical Condition

Condition

Medication

How would moving home improve this condition?

Question Title

* Medical Condition

Condition

Medication

How would moving home improve this condition?

Question Title

* Medical Condition

Condition

Medication

How would moving home improve this condition?

Getting Around in Your Home

Question Title

* Do you have difficulty walking?

Yes

No

Question Title

* If yes, are any of the following used?

Walking stick

Walking frame

Wheelchair

Question Title

* If you use a wheelchair, do you use it?

Indoors only

Outdoors only

Both

Question Title

* Is there a lift in your building?

Yes

No

Stairs

Question Title

* Do you have difficulty climbing stairs?

Yes

No

Question Title

* Do you have to go upstairs to the following? (please tick)

Toilet

Bathroom

Bedroom

Question Title

* How many stairs are there in your property?

Inside

Outside

Question Title

* How many stairs can you manage overall?

Inside

Outside

Bathroom

Question Title

* Does your bathroom have? (please tick)

Shower over bath

Separate shower unit

Wet floor shower

Bath only

Question Title

* Do you have difficulty using any of the following? (please tick)

Bath

Shower

Toilet

Question Title

* Which facilities would best suit your medical needs? Please select ONE option

Bath only

Shower over bath

Separate shower unit

Wet floor shower

Barrhead Tenants Only
In some cases, Barrhead Housing Association may be able to adapt your home to make it more suitable for your needs allowing you to remain in your current accommodation. In this case, we would refer your application to an Occupational therapist.

Question Title

* Do you wish to consider this option?

Yes

No

Other Health Problems

Question Title

* If your health problem is not covered by any of the above questions, please describe how your current accommodation affects your health or disability, and why a move would benefit your health.

Doctor/Hospital
Please provide details of your family doctor and any constants you see on a regular basis.

Question Title

* Doctor

Name

Surgery Address

Telephone Number

Question Title

* Consultant

Name

Department

Hospital

Other Support
If you get support from anyone else, such as homecare services or assistance with personal care functions, district nurse, psychiatric nurse or occupational therapist, please provide their names and addresses.

Question Title

* Support Details

Name

Occupation

Address

Telephone Number

Question Title

* Support Details

Name

Occupation

Address

Telephone Number

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50% of survey complete.