The common housing register.pmd - Gravesham Borough Council

Gravesham Borough Council The Common Housing Register application form May 2004
Details of other people living at this address
(do not include those shown in question 1 above)
Name if known Date of birth Male/Female Relationship to applicant
(if none please state ‘None’)
Medical factors
Please give details of any medical factors, mental or physical, affecting you, or a member of your
family, which you feel would be improved or assisted by moving.
Is the person or persons reffered to above, on any long-term medication which relates to their
housing application? Yes No
If yes, please state the name and the dosage.
Has the medical condition reffered to above resulted in an overnight stay in hosptial during the
past twelve months? Yes No
If yes, please give date(s) and name of hospital.
Name and address of GP
Name and address of Specialist/consultant if applicable
Name and address of Social Worker/Care Manager/CPN/Occupational therapist if applicable
Have any adaptations been carried out to make your home suitable for a disabled person in your
household? Yes No
If yes, please give details.
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