Stirling Council Housing And Customer Service Housing Application Form Page 28
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32Disabilities
Please tell us about any disabilities you or your household may have by ticking (4).
By ‘disability’ we mean any mental or physical impairments which have a substantial or long
term effect on your/their ability to carry out day-to-day activity.
Do you or anyone in your household to be housed
Yes
No
with you, consider themselves disabled?
Please tick (4
)
If you have answered Yes, is your disability one of the following. Please tick (4) relevant
boxes.
Physical disability/mobility impairment:
Learning Disability: such as
difficulty using your arms/hands or
Down’s Syndrome, dyslexia or
mobility issues that mean you may need
cognitive impairment such as an
to use a wheelchair/crutches/other
autistic spectrum condition
walking aids
Long term illness or health
Mental health condition for example
condition, for example cancer,
schizophrenia or depression
diabetes, chronic heart disease,
epilepsy or HIV
Hearing Impairment, such as being deaf
or having serious problems with your
Other (please specify)
hearing
Visual Impairment- such as being blind or
having serious problems with your sight
Religion/Faith
Please tell us your main religion/faith by ticking (4).
No religion/faith
Jewish
Christian (all denominations)
Sikh
Buddhist
Other (please specify)
Muslim
Choose not to answer
Hindu
Sexuality/Sexual Orientation?
Please tell us your sexuality by ticking (4).
Heterosexual
Gay Man
Gay Woman/Lesbian
Bisexual
Not Sure
Choose not to answer
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