PIP - Personal Independence Payment

1. About You

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

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

Tick either Yes or No for each question...

4. Eating and drinking

Tick either Yes or No for each question...

5. Managing therapy or monitoring a health condition.

Tick either Yes or No for each question...

6. Washing and bathing

Tick either Yes or No for each question...

7. Managing toilet needs or incontinence.

Tick either Yes or No for each question...

8. Dressing and undressing

Tick either Yes or No for each question...

9. Communicating verbally

Tick either Yes or No for each question...

10. Reading

Tick either Yes or No for each question...

11. Engaging with other people

Tick either Yes or No for each question...

12. Managing Money

Tick either Yes or No for each question...

13. Planning and following journeys

Tick either Yes or No for each question...

14. Moving around

Tick either Yes or No for each question...

15. Additional questions

Tick either Yes or No for each question...

16. Submission