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Personal Independence Payment Enquiry Form

Basic Contact Information

Personal Independence Payment - Eligibility Questions

When answering the questions that follow please 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.

Please describe your illness or disability:

1. Preparing Food

Tick either Yes or No for each question...

Can you peel and chop vegetables?
Yes No
Can you open a packet?
Yes No
Can you stand long enough to cook?
Yes No
Do you need any supervision? e.g. you might go dizzy, fall or have a seizure.
Yes No
Do you need someone to encourage you to cook?
Yes No
Can you see well enough to use a microwave?
Yes No
Can you see well enough to read instructions?
Yes No
Do you know how long to cook something for?
Yes No
Can you tell if food has gone off?
Yes No
If you do prepare food, does it take you more than twice as long as anyone else?
Yes No
Do you use any aids to help you in the kitchen? e.g. a perching stool.
Yes No
Can you lift and safely carry hot items? e.g. out of an oven or hot pans.
Yes No
Do you have to take breaks between tasks due to the pain or fatigue it causes?
Yes No
Anything else you would like to add?

2. Eating and drinking

Tick either Yes or No for each question...

Can you use a knife and fork to cut food?
Yes No
Can you hold a cup?
Yes No
Can you get food to your mouth without spilling it?
Yes No
Do you need encouraging to eat?
Yes No
Have you ever been given diet supplements?
Yes No
Do you use any aids to help you eat?
Yes No
When eating, does it take you more than twice as long as anyone else?
Yes No
Do you tend to eat softer food so you don't have to ask for help?
Yes No
Do you choke when you try to eat?
Yes No
Can you swallow food and drink?
Yes No
Do you class yourself as overweight?
Yes No
Do you class yourself and underweight?
Yes No
Anything else you would like to add?

3. Managing therapy or monitoring a health condition.

Tick either Yes or No for each question...

Do you use a pill box?
Yes No
Do you have any special exercises? e.g. physiotherapy to do at home.
Yes No
Do you use any equipment? e.g. TENS machine, blood sugar monitor and do you need any help to use it?
Yes No
Can you get medication out of foil or bottles?
Yes No
Do you need reminding to take medication?
Yes No
Can you see to read the instructions on medication?
Yes No
Can you tell your medication apart?
Yes No
Anything else you would like to add?

4. Washing and bathing

Tick either Yes or No for each question...

Do you need help or support to get in and out of the shower?
Yes No
Can you wash your hair?
Yes No
Can you wash your feet?
Yes No
Can you cut your toenails?
Yes No
Can you wash your back?
Yes No
Can you wash your neck?
Yes No
Do you need someone with you when you are washing or bathing in case you fall, go dizzy or have a seizure?
Yes No
Does someone prompt you to wash?
Yes No
Do you know when you need to wash or bathe?
Yes No
When washing or bathing does it take you more than twice as long as anyone else?
Yes No
Do you have any aids? e.g. long handled sponge or seat in the bath/shower.
Yes No
Can you stand freely under the shower or do you hold onto something or someone or lean against the wall?
Yes No
Do you need help to dry yourself?
Yes No
Do you need to rest after bathing?
Yes No
Do you need help to wash your hair?
Yes No
Do you need help to shave?
Yes No
Anything else you would like to add?

5. Managing toilet needs or incontinence.

Tick either Yes or No for each question...

Do you use pads to manage incontinence?
Yes No
Do you need someone with you when you are using the toilet in case you fall, go dizzy or have a seizure?
Yes No
Do you struggle to clean yourself after using the toilet?
Yes No
Do you need any help to get on or off the toilet?
Yes No
Do you use anything to support you on and off the toilet? e.g. a radiator, sink.
Yes No
Do you have any aids? e.g. a raised toilet seat.
Yes No
Do you need anyone to remind you to use the toilet?
Yes No
Anything else you would like to add?

6. Dressing and undressing

Tick either Yes or No for each question...

Do you wear appropriate clothing for the weather conditions?
Yes No
Do you change your clothes when they are dirty?
Yes No
Can you dress your upper body?
Yes No
Can you dress your lower body?
Yes No
Do you need someone to encourage you to get dressed?
Yes No
Do you have to sit down to dress in case you fall, go dizzy or have a seizure?
Yes No
Do you use any aids to help you dress?
Yes No
Anything else you would like to add?

7. Communicating verbally

Tick either Yes or No for each question...

Do you use an aid to help you speak?
Yes No
Do you use and aid to help you hear?
Yes No
Do you need someone to explain basic sentences to you?
Yes No
Do you need someone to explain complicated sentences to you?
Yes No
Do you talk to people on the phone?
Yes No
Do you text people?
Yes No
Anything else you would like to add?

8. 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?

9. 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?

10. Managing Money

Tick either Yes or No for each question...

Do you make purchases in shops or online?
Yes No
Have you been or are you in debt?
Yes No
Do you have any county court judgements?
Yes No
Did you pass your maths and English exams at school?
Yes No
If you pay with cash do you know how much change to expect?
Yes No
Does someone help you with your bills?
Yes No
Anything else you would like to add?

11. Planning and following journeys

Tick either Yes or No for each question...

Do you have severe anxiety or panic attach when you try to go outdoors?
Yes No
Do you have agoraphobia?
Yes No
Can you read a bus or train timetable?
Yes No
Can you plan a journey with a timetable?
Yes No
Can you read road or street signs?
Yes No
Can you work out how to get to a place using a map?
Yes No
Do you need someone to guide you or to be with you in case you fall, go dizzy or have a seizure?
Yes No
Do you need someone with you as you cannot hear announcements or people speaking to you?
Yes No
Anything else you would like to add?

12. Moving around

Tick either Yes or No for each question...

Can you stand on your feet?
Yes No
Can you stand and then move more than 200 metres, either aided or unaided?
Yes No
Can you stand and then move more than 50 metres but no more than 200 metres, either aided or unaided.
Yes No
Can you stand and then move unaided more than 20 metres but no more than 50 metres?
Yes No
Can you stand and then move using an aid or appliance more than 20 metres but no more than 50 metres?
Yes No
Can you stand and then move 1 metre but no more than 20 meteres, either aided or unaided?
Yes No
Do you walk with a limp or altered gait?
Yes No
Do you have problems managing kerbs?
Yes No
Do you walk at least a third as fast as the average person?
Yes No
Do you fall, go dizzy or have a seizure?
Yes No
Anything else you would like to add?

13. 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

16. Submission