Manitoba Housing Medical Information Form (Page 2 of 2) in pdf

MEDICAL INFORMATION

To be completed by the medical professional

Please check the appropriate boxes and print additional information as required.

Does the patient require accessible housing due to a physical disability?  Yes  No

Does the patient have a disability that prevents them from working and taking part in training for 12 months or more?

 Yes  No

Does the patient need to move out of their current home for medical reasons?

If yes, please explain (e.g. proximity to support services, mobility issues, mental health limitations).

_______________________________________________________________

Does the patient require any physical enhancements in their housing to live independently or accommodate medical

 Yes  No

conditions?

If yes, please describe their condition and the enhancements required (e.g. elevator, grab bars, extra space for

medical equipment)

_______________________________________________________________

Is the patient currently pregnant?  Yes  No

If yes, what is the due date of the baby: ____________________________________________________________

Medical Professional Information:

Name: ___________________________________________________ Phone: _______________________________

Please print

Address: _______________________________________________________________________________________

Signature: _________________________________________________ Date: ________________________________

Manitoba Housing Medical Information Form Page 2