Current accommodation

Type of home?

Getting around your home

Do you have difficulty walking?

If yes, do you use any of these to help get around?

If you use a wheelchair, do you use it indoors or outdoors?

Do you have any difficulty climbing stairs?

Are there any handrails on the stairs?

Do you have to go upstairs to the:

Do you require any equipment to help you with the stairs?


What does your bathroom have?

Do you have any difficulty using the bath, shower or toilet?

Do you have any aids or equipment to assist you in the bathroom?

Disability benefits

Do you receive any benefits due to your health problems or disability?

Other health problems


Do you regularly attend a hospital or clinic?

Family doctor and other support

Do we have permission to contact any of the above people if we need more information about your health?