Northampton Community Health Support Questionnaire
Your responses to the questions below could strengthen our application and improve our ability to secure the support needed. Thank you in advance.
Have you ever had mould in your home?
*
Yes
No
Not sure
If yes, is the mould:
Still present
Been resolved
Comes back regularly
Have you ever seen a GP or been referred for any breathing or respiratory-related problems?
*
Yes
No
If yes, please tick any that apply:
Asthma
COPD
Chest infections
Long-term cough
Shortness of breath
Other
Does anyone in your household smoke or vape? (They don’t need to smoke indoors, just whether they are a smoker or vaper.)
*
Yes
No
If yes:
I smoke
Someone else in the home smokes
Both
Would you like support with any of the following?
*
Help with mould or housing concerns
Support to stop smoking
Support to stop vaping
Help with breathing or lung health
General health advice
Not at the moment
Is there anything else you would like support with?
What is your postcode?
*
Your name (optional)
First Name
Last Name
Email address (optional)
example@example.com
Submit
Should be Empty: