Online Medical Questionnaire

If you need help using any of our online services, please call us on 0121 717 1515. You are welcome to nominate a friend or advocate to speak to us on your behalf if that helps you.

You can also visit Connect Offices in Solihull town centre and Chelmsley Wood town centre where staff will be able to help you in person.

The Medical Assessment process will determine the impact that your current housing has on the health of any member of your household. Consideration is given as to whether the overall impact is sufficiently severe to warrant additional priority on medical grounds.

If there is no indication that current housing circumstances may impact adversely on the health of your household, you will be advised of such in writing.

For problems due to neighbour nuisance, repairs or damp please call 0121 717 1515 for advice in the first instance as we may not consider these as medical issues.

Do you have an active housing application? *

Have you applied to the housing register? *

We cannot accept Medical Assessment Questionnaire submissions if no housing application has been made. Please click here to make a housing application.

Solihull Home Options PIN Number *

Do you have a local connection to Solihull? *

You can find out if you have a local connection by clicking here.

We cannot accept Medical Assessment Questionnaire submissions if you do not have a local connection to Solihull.

1. Applicant Details

Name *

First

Last

Date of Birth *

Gender *

You have selected 'Other', please provide details *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Phone *

Email *

Preferred method of contact *

Current property type *

You have selected 'Flat', please indicate which floor you live on *

You have selected 'Other', please provide details *

Is there a lift? *

2. Details of person with medical condition (if different from applicant)

Are you the person with the medical condition? *

Name *

First

Last

Phone *

Date of Birth *

Gender *

You have selected 'Other', please provide details *

3. Consultant Details

Does the person with the medical condition have a consultant? *

Consultant's Name *

First

Last

Consultant's phone *

Please detail the condition that the consultant is treating *

4. Medical Condition

What is the medical condition? *

How does the current accommodation affect your/their condition? *

Why would alternative accommodation help your/their condition? *

Proof of your (or a member of your household's) medical condition and why your current accommodation is affecting the condition must be provided from a professional e.g. GP or Consultant Specialist. Your application will not be processed until this has been provided.

Screenshots from the NHS app will be accepted.

5. Medication

Do you take medication? *

Please list below details of the medication, including the dosage and frequency of use *

Proof of medication must be provided which must be no more than 3 months old.

6. Giving or Receiving Support

Do you need to give or receive support from another person who lives in Solihull? *

Give support
Receive support
N/A

Person's name *

First

Last

Person's address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Relationship to you *

What support do you give? *

What support do you receive? *

7. Occupational Therapist/Health Professional Details

Does the person with the medical condition have an Occupational Therapist or other health professional? *

Professional's name *

First

Last

Professional's phone *

Please detail the condition that the Occupational Therapist or other health professional is treating *

8. Adaptations

Do you have adaptations in your home? *

What adaptations do you have in your current home? *

Grab rails
Ground floor bedroom/bathroom
Ramps
Shower cubicle
Shower over bath
Stair lift
Vertical lift
Wet room
Wider doors
Other

Please describe what other adaptations you have in your home *

Do you feel you need adaptations in your new home? *

What adaptations do you feel you need in your new home? *

Grab rails
Ground floor bedroom/bathroom
Ramps
Shower cubicle
Shower over bath
Stair lift
Vertical lift
Wet room
Wider doors
Other

Please describe what other adaptations you feel you need in your new home *

Do you use a wheelchair inside your property? *

Are you a Blue Badge holder? *

If you (or a member of your household) have a disability/mobility issues, we may refer these details to our Housing Occupational Therapist.

9. Benefits & Employment

Please tick below what benefits you are currently in receipt of or advise if you are employed *

Employed
Universal Credit
Jobseeker's Allowance (JSA)
Employment & Support Allowance (ESA) or Incapacity Benefit
Disability Living Allowance (DLA)
Personal Independence Payment (PIP)
Other

You have selected 'Other, please provide details *

Your benefit award letter will need to be provided. Bank statements or screenshots from a banking app will not be accepted.

10. Proof/Supporting Evidence

We will not process your questionnaire without proof/supporting evidence.

This should be no more than 3 months old (we may accept documents older than this in some circumstances e.g. long-term conditions).

Accepted forms of proof/supporting evidence are:

a) GP patient summary/statement - click here (pdf 120 kB) to download the statement template
(please note - SCH will not reimburse any charges incurred)
b) Hospital clinic letters and/or discharge summaries
c) Confirmation of diagnosis
d) Medication (e.g. copy of prescriptions)
e) Proof of benefit
f) Support letters from medical professionals

Upload evidence file(s) here

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

If proof/supporting evidence is not provided within 4 weeks of submission, the application will be closed.

If further information is requested by SCH, it will need to be supplied within 2 weeks or the application will be closed.

11. Declaration

Please check the information you have provided is correct. Please read and agree to the following statements *

I/We declare that, to the best of my/our knowledge that the information supplied on this form is correct and that I/We will inform Solihull Home Options, Solihull Council, Solihull Community Housing or the partner Housing Associations of any changes in my circumstances.

Checkboxes *

I/We understand that under the Housing Act 1995 section 171 that it is an offence to make a false statement, either knowingly or recklessly, to a local authority in connection with any request for housing assistance.

It is also an offence to withhold information, which is requested by Solihull Home Options, Solihull Council, Solihull Community Housing or partner Housing Associations *

I/We understand that any person found guilty of an offence under this section is liable to a fine of up to £5,000.

Where a tenancy has been granted and it is later found that false or misleading information has been given or information has been withheld, the Council or partner Housing Associations may commence possession proceedings for the recovery of the property. *

I/We understand that in these circumstances, I/we may lose the right to be re-housed by Solihull Council and partner Housing Associations.

Checkboxes *

I/We understand that Solihull Home Options, Solihull Council or Solihull Community Housing and partner Housing Associations make enquiries regarding this application.

Would you like a copy of this email sent to you for your own records? *

GDPR Statement - The information you provide will be used to assist us in understanding your enquiry or experience. We may also use it to communicate with you and provide the services you need or are entitled to receive and to monitor our performance in providing services to you; to gather statistical information to allow us to plan future provision of services and to obtain your opinion about our services. We may share data with other council services & partner organisations to ensure records are kept accurate and to identify services or benefits you may be entitled to or interested in. It is therefore very important that you notify us if any of the information you have provided changes at any time. We may also need to share your information for the prevention and detection of fraud and/or other crimes or as the law requires. If you would like to learn more about how Solihull Community Housing uses personal data, please refer to our full Privacy Notice on the website.

The Medical Assessment process will determine the impact that your current housing has on the health of any member of your household. Consideration is given as to whether the overall impact is sufficiently severe to warrant additional priority on medical grounds.

If there is no indication that current housing circumstances may impact adversely on the health of your household, you will be advised of such in writing.

For problems due to neighbour nuisance, repairs or damp please call 0121 717 1515 for advice in the first instance as we may not consider these as medical issues.

We cannot accept Medical Assessment Questionnaire submissions if no housing application has been made. Please click here to make a housing application.

You can find out if you have a local connection by clicking here.

We cannot accept Medical Assessment Questionnaire submissions if you do not have a local connection to Solihull.

1. Applicant Details

2. Details of person with medical condition (if different from applicant)

3. Consultant Details

4. Medical Condition

Proof of your (or a member of your household's) medical condition and why your current accommodation is affecting the condition must be provided from a professional e.g. GP or Consultant Specialist. Your application will not be processed until this has been provided.

Screenshots from the NHS app will be accepted.

5. Medication

Proof of medication must be provided which must be no more than 3 months old.

6. Giving or Receiving Support

7. Occupational Therapist/Health Professional Details

8. Adaptations

If you (or a member of your household) have a disability/mobility issues, we may refer these details to our Housing Occupational Therapist.

9. Benefits & Employment

Your benefit award letter will need to be provided. Bank statements or screenshots from a banking app will not be accepted.

10. Proof/Supporting Evidence

We will not process your questionnaire without proof/supporting evidence.

This should be no more than 3 months old (we may accept documents older than this in some circumstances e.g. long-term conditions).

Accepted forms of proof/supporting evidence are:

a) GP patient summary/statement - click here (pdf 120 kB) to download the statement template

b) Hospital clinic letters and/or discharge summaries

c) Confirmation of diagnosis

d) Medication (e.g. copy of prescriptions)

e) Proof of benefit

f) Support letters from medical professionals

If proof/supporting evidence is not provided within 4 weeks of submission, the application will be closed.

If further information is requested by SCH, it will need to be supplied within 2 weeks or the application will be closed.

11. Declaration