Medical Housing Assessment Application Form Page 6
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12Section 2 – Your present home
What type of property do you live in?
House
Flat
4 in a block
(property with internal stairs)
(own entrance)
(own entrance)
Bungalow
Flat
4 in a block
(communal entrance)
(communal entrance)
Sheltered housing
Maisonette (ground)
Amenity housing
st
Supported housing
Maisonette (1
floor)
Other (please state)
If you reside in a flat or 4 in a block type accommodation what floor is your property on (please tick):
st
rd
Basement
1
floor
3
floor
nd
th
Ground floor
2
floor
4
floor or over
How long have you lived at this address?
How many bedrooms are there in this property?
Layout of your current home: (Please tick all that apply)
Bathroom upstairs
Outside steps to entrance
Bathroom downstairs
Bedroom upstairs
Toilet upstairs
Bedroom downstairs
Toilet downstairs
Curved internal staircase
Straight internal staircase
Are you the:
Tenant
Living with family
Lodger
Owner
Living with non-family
Other (please state)
Who lives in the property with you?
Name
Date of birth
Relationship to person with health issue or disability
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