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Disability Allowance Enquiry Form

Basic Contact Information

About the child's illnesses or disabilities

Please use the table below to tell us about the illnesses or disabilities that your child has.
Illness or disability How long have they had it? What treatment do they have for it? How often do they have treatment?
Example: ADHD Problems started aged 4 Cognitive behaviour therapy.
Ritalin 30 milligrams (mg) 		One hourly session a week.
One a day

Mobility

Can they physically walk?
Tick No if they cannot walk at all.
Yes No
Do they have physical difficulties walking?
This means problems with how far they can walk, how long it takes, their walking speed, they way they walk, or the effort of walking and how this may affect their health.
Yes No
Please tick the boxes that best describe how far they can walk without severe discomfort and how long it takes them.
They can walk:
over 200 metres (218 yards) 51 to 200 metres (56 to 218 yards) 50 metres (55 yards or less) A few steps
It takes them:
More than 5 minutes 3 - 4 minutes 1 - 2 minutes Less than a minute
Please tick the circle that best describes their walking speed:
Normal
This means they can easily keep up with friends.
Slow
This means they can only keep up with friends with a lot of effort.
Very Slow
This means they can't keep up with friends.
Please tick the box that best describes the way they walk.
They:
walk normally
walk with a limp
shuffle
drag their leg
walk with one or both feet turned inwards
walk on their toes
have poor balance
If they have other difficulties with the way they walk, tell us below what they are.
This is not a required field.
Does the effort of walking seriously affect their health?
For example, walking can cause bleeding into the knee and ankle joints.
Yes No
Please tell us how their health is affected.
If you want to tell us why you have ticked the boxes above, how their needs vary or anything else you think we should know, use the box below.
For example, they have more pain or tiredness if they walk too far the day before.
Do they need guidance or supervision most of the time when they walk outdoors?
Yes No
Can they:
find their way around places they know?
Yes No
ask for and follow directions?
Yes No
walk safely next to a busy road?
Yes No
cross a road safely?
Yes No
understand common dangers outdoors?
Yes No
Do they regularly:
become anxious, confused or disorientated?
Yes No
display unpredictable behaviour?
Yes No
need physical restraint?
Yes No
refuse to walk?
Yes No
Do they fall due to their disability?
Yes No
Tell us the number of falls each month
Can they get up without help?
Yes No
Have they had injuries needing hospital treatment?
Yes No
If you want to tell us why you have answered as you have, how their needs vary or anything else you think we should know, use the box below.
For example, they are frightened by loud noises and behave without thinking about danger.

Care

Do they need encouragement, prompting, or physical help to get into or out of or settle in bed during the day?
Yes No
Tell us how often they need help each day and how long it takes each time.
They need encouragement, prompting or physical help to: How often each day How long each time (in minutes)
wake up
get out of bed
get into bed
settle in bed
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they may need to follow a set routine to go to or get out of bed.
Do they need encouragement, prompting, or physical help to go to or use the toilet during the day?
This means going to the toilet, using the toilet, cleaning themselves and coping with continence care.
Yes No
Do they need help to:
Go to the toilet
Yes No
Manage clothes
Yes No
Get on and off the toilet
Yes No
Wipe themselves
Yes No
Wash and dry their hands
Yes No
Manage a catheter, ostemy or stoma
Yes No
Manage nappies or pads
Yes No
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.
For example, they have pain and become distressed.
Do they need encouragement, prompting, or physical help to move around indoors, use stairs or get into or out of a chair during the day?
A chair is any type of chair including a wheelchair.
This means moving from one place to another, using stairs, getting into, sitting in, and getting out of a chair. Indoors is in their home, a friend's home, school, college or anywhere else inside.
Yes No
They need encouragement, prompting or physical help to:
go up and down one step
Yes No
go upstairs
Yes No
go downstairs
Yes No
move around safely
Yes No
get into or out of a chair
Yes No
sit in a chair
Yes No
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.
For example, they bump into furniture and doors.
Do they need encouragement, prompting, or physical help to wash, bath, shower and check their appearance during the day?
This means getting in and out of a bath or shower, washing their hair, drying themselves, using scoop, using a toothbrush and checking their appearance.
Yes No
Tell us how often they need help each day and how long it takes each time.
They need encouratement, prompting or physical help to: How often each day How long each time (in minutes)
have a wash
clean their teeth
wash their hair
get in or out of the bath
get in or out of the shower
clean themselves in the bath or shower
dry themselves after a bath or shower
check their appearance
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, when they are in the bath they need telling repeatedly what to do and how to do it.
Do they need encouragement, prompting, or physical help to dress and undress during the day?
This means choosing the right clothes for the weather or activity, choosing clean clothes, putting clothes on in the correct order, moving their arms or legs to put clothes on or take them off. This is any dressing or undressing except when using the toilet.
Yes No
Tell us how often they need help each day and how long it takes each time.
They need encouratement, prompting or physical help to: How often each day How long each time (in minutes)
dress
undress
manage zips, buttons or other fastenings
choose appropriate clothes
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they follow a set routine that takes a long time.
Do they need encouragement, prompting, or physical help to eat and drink during the day?
This means getting food into their mouth, chewing, swallowing, using cutlery, cutting up food, holding a cup, getting it to their mouth and drinking.
Yes No
Tell us how often they need help each day and how long it takes each time.
They need encouratement, prompting or physical help to: How often each day How long each time (in minutes)
eat
use a spoon
cut up food on their plate
drink using a cup
be tube or pump fed
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they follow a set routine that takes a long time.
Do they need encouragement, prompting, or physical help to take medicine or have therapy during the day?
Taking medicine includes tablets, injections, eye drops, knowing what to take, how much to take and when to take it.
Having therapy includes blood sugar testing, peak flow checks, physio, oxygen, speech, play and behaviour therapy, knwowing what to do, how much to do and when to do it.
Yes No
Tell us how often they need help each day and how long it takes each time.
They need encouratement, prompting or physical help to: How often each day How long each time (in minutes)
take the correct medicine
know when to take their medicine
do their therapy
know when to do their therapy
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they become angry with their condition and refuse to take their medicine.
Do they have difficulty seeing?
This means when using their aids like glasses or contact lenses.
Yes No
Are they certified sight impaired or severely sight impaired?
Certified severly sight impaired
Certified sight impaired
They can see: Yes No
computer keyboard keys or large print in a book
a TV and follow the actions to a story
the shape of furniture in a room
They can recognise: Yes No
someone's face across a room
someone across a street
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they have difficulty seeing in poorly lit places like a cinema.
Do they have difficulty hearing?
This means hearing sound or someone communicate when using their hearing aid.
Yes No
They can hear: Yes No
a whisper in a quiet room
a normal voice in a quiet room
a loud voice in a quiet room
a TV, radio or CD but only at a very loud volume
a school bell or car horn
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they can't hear things if there is a lot of background noise.
Do they have difficulty speaking?
This means the ability to say words out loud and talk clearly.
Yes No
They can: Yes No
speak clearly in sentences
put words together to make simple sentences
speak single words
They can communicate using speech: Yes No
with someone they know
with someone they don't know
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they get embarrassed about the way they talk and will only speak to people they know.
Do they have difficulty and need help communicating?
This means passing on information, asking and answering questions, telling people how they feel, giving and following instructions.
Yes No
To communicate they use: Yes No
writing
BSL (British Sign Language)
lip-reading
using hand-movements, facial expressions and body language
Makaton
If they use another form of communication, tell us below what it is. THis could be Sign Supported English (SSE), Signed Englis(SE), Finger Spelling, Picture Exchange Communication System (PECS), Tadoma or something else.
They can communicate: Yes No
with someone they know
with someone they don't know
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they may be at risk because they don't understand writing.
Do they have fits, blackouts, seizures, or something similar?
This means epileptic, non-epileptic or febrile fits, faints, absences, loss of consciousness and 'hypos' (hypoglycaemic attacks).
Yes No
They: Yes No
have no warning
have had a serious injury in the last 6 months because of a fit, blackout or seizure
display dangerous behaviour after a fit, blackout or seizure
Tell us:
the number of days affected each month days
how many fits they have on these days
the number of nights affected each month nights
how many fits they have on these nights
Have they had an episode of status epilepticus in the past 12 months?
This is where there is persistent epileptic activity for more than 30 minutes, or they have several seizures without becoming conscious between each seizure.
Yes No
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they become distressed and need reassurance.
Do they need to be supervised during the day to keep safe?
This means they need someone to keep an eye on them because of how they feel or behave, or how they react to people, changing situations and things around them.
Yes No
Can they: Yes No
recognise and react to common dangers
cope with planned changes to daily routine
cope with unplanned changes to daily routine
Do they regularly: Yes No
feel anxious or panic?
become upset or frustrated?
harm themselves or others?
feel someone may harm them?
become verbally or physically aggressive or destructive?
act impulsively?
have tantrums?
If you want to tell us why they need help, how their needs vary or anything else you think we should know, use the box below.
For example, they behave without thinking about dangers or how it will affect others.
Do they need extra help with their development?
This means any extra help they need to improve their understanding of how to behave and react to people, situations and things around them.
Yes No
They need help to: Yes No
understand the world around them
recognise their surroundings
follow instructions
play with others
play on their own
join in activities with others
behave appropriately
understand other people's behaviour
If you want to tell us why you have ticked the boxes, how their needs vary or anything else you think we should know, use the box below.
For example, they may have difficulty making friends.

Submission