Name
Address (including postcode)
Date of birth
Telephone number
Please tell us what health problem you or anyone else in your household have:
Type of home?
If it is a flat, what level is it on?
What type of property do you wish to move to?
Do you have difficulty walking?
If yes, do you use any of these to help get around?
If you use a wheelchair, do you use it indoors or outdoors?
Do you have any difficulty climbing stairs?
If yes, please give details:
Please indicate how many stairs there are inside your home?
Please indicate how many stairs there are outside your home?
Are there any handrails on the stairs?
How many stairs would you be able to manage easily?
Do you have to go upstairs to the:
Do you require any equipment to help you with the stairs?
What does your bathroom have?
Do you have any difficulty using the bath, shower or toilet?
If yes, please tell us about it:
Do you have any aids or equipment to assist you in the bathroom?
Do you receive any benefits due to your health problems or disability?
If yes, please tell us which benefit and the rate e.g. mobility, middle rate
If your health problem is not covered by any of the above questions, please tell us how your housing affects your illness or disability, and how you feel a move would help
Do you regularly attend a hospital or clinic?
If yes, which hospital or clinic?
What is your consultant's name?
What is your doctor's name
Address
If you get regular support from anyone else, such as district nurse or occupational therapist, please give their names and addresses:
Do we have permission to contact any of the above people if we need more information about your health?
