1. About You

Name

Date of Birth

Address

House name /Number

Street

Town

County

Post Code

Contact Details

Phone

Mobile Phone

Your condition or disability

Please feel free to attach more information e.g. letters from your GP or hospital.

2. Your contact preferences

I prefer to be contacted by:

mobile phone

text

home phone

The best days and times to contact me are: (please tick preference)

Monday

between

and

Tuesday

between

and

Wednesday

between

and

Thursday

between

and

Friday

between

and

When answering the questions that follow we want uou to select the answer that is for most of the time. So if you tick 'no' to 'can you peel and chop vegetables?' you are saying that most days (more than half the time) you cannot do this.

3. Preparing Food

4. Eating and drinking

5. Managing therapy or monitoring a health condition.

6. Washing and bathing

7. Managing toilet needs or incontinence.

8. Dressing and undressing

9. Communicating verbally

10. Reading

Tick either Yes or No for each question...

Do you use an aid (other than spectacles or contacts) so you can read?

Yes No

Do you need prompting to read?

Yes No

Can you read signs and symbols? e.g. street signs or bus numbers.

Yes No

Do you need someone to help you with paperwork e.g. bills?

Yes No

Anything else you would like to add?

11. Engaging with other people

Tick either Yes or No for each question...

Do you need prompting to engage with other people in a social setting?

Yes No

Do you get anxious or distressed in a social setting?

Yes No

Anything else you would like to add?

12. Managing Money

13. Planning and following journeys

14. Moving around

15. Additional questions

Tick either Yes or No for each question...

Do you work?

Yes No

If YES, please give details.

Do you have any pets?

Yes No

If YES, please give details.

Do you drive?

Yes No

If YES, please give details.

If YES, do you drive manual or automatic type cars?

Manual Automatic

PIP - Personal Independence Payment

1. About You

2. Your contact preferences

I prefer to be contacted by:

The best days and times to contact me are: (please tick preference)

3. Preparing Food

4. Eating and drinking

5. Managing therapy or monitoring a health condition.

6. Washing and bathing

7. Managing toilet needs or incontinence.

8. Dressing and undressing

9. Communicating verbally

10. Reading

11. Engaging with other people

12. Managing Money

13. Planning and following journeys

14. Moving around

15. Additional questions

16. Submission