Housing Medical Assessment Application
Housing Medical Assessment
PLEASE READ THE NOTES BELOW BEFORE COMPLETING THIS FORM.
This medical form is not an application for housing. Only complete this form if you have already applied for the Housing Register via HomeChoice.
Complete this form if either you, or a member of your household who will be housed with you, suffers from ill health, a physical or learning disability or a mental health problem which is being affected by your current housing.
- All Medical Assessment Forms are considered by an independent medical advisor.
- Priority is only awarded where it is clear that there is a direct link between someone’s health problems and their current accommodation.
- You must complete this form yourself. Please do not ask your doctor to complete it for you. We also need you to provide a copy of your prescription list and recent medical letter / report about your health condition(s) from your doctor, health worker or occupational therapist. These can be routine letters you do not need to pay for a GP medical report.
- Please answer all questions in black ink and in BLOCK CAPITALS
- A separate form must be completed for every person named on your housing application form who has a health problem.
- Please make sure you fill in ALL the sections that apply. If you do not, we will return the form to you as your case cannot be assessed properly without full information.