C o n f i d e n t i a l

Medical Report
To be completed by treating doctor

A range of housing assistance options are available to help Queenslanders with their housing needs. We need detailed information about any housing needs in relation to your patient’s medical condition or disability. Completing this form with accurate and comprehensive details about current barriers and ongoing requirements will assist us to identify an appropriate housing response for your patient. A separate Medical Report must be completed for each person in the household who has a medical condition or disability that affects their housing needs.

Patient’s full name:	Date of birth:	/	/	
How long have you treated this patient?	
When did you last see this patient?		
Patient’s weight:	Patient’s height:	
List any medical condition or disability that currently, or in the future, will impact on your patient’s ability to obtain or sustain a housing tenancy (attach signed further information if required).	

	
Provide details of how the above listed medical condition or disability impacts on the patient’s ability to obtain or sustain a housing tenancy (attach signed further information if required).	

	
How long will your patient’s medical condition or disability impact on obtaining or sustaining a housing tenancy? e.g. injury is significant and permanent, or a long term serious health /medical condition or illness?	
What aspects of your patient’s current accommodation adversely affects their medical condition or disability, include any details of homelessness if applicable	

	
	
How would a change in your patient’s accommodation improve their overall capacity to function.	

	
Which of the following housing features does your patient require to assist their medical condition or disability?	
Ground floor	Modifications, such as grab rails	Lowset, maximum steps?  	 Locational need, such as close to hospital or support	Wheelchair access
Requires overnight care	Other	

C o n f i d e n t i a l

Provide details of how the selected housing features, or an alternative housing feature, will assist with your patient’s medical condition or disability.	

	
Provide details of any other medical/health or support services that your patient receives, if known.	

	
Provide details of any decision-making support arrangements that your patient has in place, if known.
Such as Office of the Public Guardian, Public Trustee, Power of Attorney.	

	
Provide details of any information in this report which, if released to your patient, might be detrimental to their physical or mental health?	

Declaration
To the best of my knowledge, the information provided in this Medical Report, and any attached documentation, is true and correct. I understand that I will commit an offence and be liable to a penalty under the Housing Act 2003 if I knowingly provide to the Department of Housing and Public Works false or misleading information.
Name:		
Qualifications:		
Practice address:		
Telephone:		Mobile:		
Email:		

Signature:	
Date:		

Registration stamp:			

/	/

Personal Information Privacy Notice

The Department of Housing and Public Works is collecting your personal information so we may provide you with housing assistance. To assist you with your housing needs and services, your personal information may be disclosed to partner agencies, service providers, local governments and non-governmental agencies that now, or will, provide you with housing and/or support services. Unless authorised or required by law, your personal information will not be disclosed to any other third party without your consent. More information about the Department’s privacy obligations is available on our website at www.housing.qld.gov.au.