Medical Assessment Form

PLEASE READ THESE NOTES BEFORE

COMPLETING THIS FORM

The key principle of assessing for medical points is that the medical condition itself will not be assessed, but whether rehousing can significantly alleviate the condition.

Only one member of a household can be awarded medical points. If more than one person has a medical condition, please complete a form for each one and the person who is likely to have the highest points awarded will be assessed.

Points will be awarded as follows:

Priority A: Extreme 50 points

Priority B: Serious 30 points

Priority C: Significant 10 points

Refused 0 points

Please complete the medical form as thoroughly as possible so that we can assess points as accurately as possible.

If you are taking medication, please include the name of the medicine, the dose and the frequency you have to take it.

We will contact you after your application has been assessed and will tell you how many medical points you have been awarded and how many points in total you have. This will be approximately 2 weeks after you have returned your medical assessment form.

If you have any difficulty reading or writing or are visually impaired or need help in completing the form, please contact us where a member of staff will be pleased to give you advice and assistance.

All applications will be treated confidentially and fairly.

SECTION 1

INFORMATION ABOUT THE PERSON

WITH THE MEDICAL CONDITION

Full Name (required)

Gender (required)

Address (required)

Telephone Number (required)

Email Address (required)

Date of Birth dd/mm/yyyy (required)

Relationship to Main Housing Applicant (required)

SECTION 2

MEDICAL DETAILS

What is your medical condition? (required)

Please describe how your present house is adversely affecting your health. (required)

Is your condition temporary or permanent? Please give details: (required)

Are you currently taking any medication? If yes, please give details:

Do you have any difficulty with walking? (required)

If yes, do you use any of the following aids:

Walking Stick

Zimmer Frame

Crutches

Wheelchair

Have you been provided with any aids to daily living (ie. handrails, bathing aids) or have any adaptations carried out to your present home as a result of your medical needs?

If yes, please give details:

Can you manage stairs? (required)

If yes, how many can you manage comfortably?

Does the heating in your current property affect your health? (required)

If yes, please give details:

Does your condition mean you need an extra bedroom? (required)

If yes, please give details:

SECTION 3

YOUR PRESENT ACCOMMODATION

How many bedrooms are there in your current accommodation? (required)

What type of house do you live in? (required)

Do you have gas or electric heating? (required)

Do you have a bathroom on the same level as your living area? (required)

If no, please tell us how many stairs there are:

Do you have a garden at present? (required)

Please describe the location of your house (ie. in hilly area, level site, etc) (required)

SECTION 4

OTHER INFORMATION

What is the name and address of your family Doctor (GP)? Include Address and Telephone Number (required)

Is there anyone who is providing you with regular care and support? (required)

If yes, please give details:

Name

Address

Telephone Number

Please detail the support this person provides you with.

Name

Address

Telephone Number

Please detail the support this person provides you with.

Do you have an Occupational Therapist, Social Worker or Specialist? (required)

If yes, please give details:

Name

Address

Telephone Number

Is there anything else that you would like to add in support of your application?

SECTION 5

DATA PROTECTION

Declaration

I hereby give permission to Knowes Housing Association to ask my family Doctor (GP), my hospital Doctor/Consultant, and any other agencies with an interest in my health for further information.

I understand that this information will be treated in the strictest confidence and that it will only be used to assess my request for medical priority for rehousing.

Signed (Please type name as confirmation) (required)

Date dd/mm/yyyy (required)