Blank Pip Form – Fill Out and Use This PDF

Step 1

– Read through this form and the Inf

rma ion Booklet.

Step 2

– Fill in this form (in pen) to tell us h

for

w y ur health condition

or disability affects you.

tep 3

– Read and sign the declarati n n page 32.

tep 4

– Return the form to us with photocopies of any additional

Please put your name and National Insurance number

n the t p f

use

each document.

Specimen

Section 1 – About your health prof ssio

als

If we need additional information we may contact the h

alth professionals that upport you.

therapist, physiotherapist, so

al worker, counsell

r, r supp t w

ker.

Name

Address

for

Postcode

Profession

Phone number including the

dialling code

When did you last see them?

/

/

(approximate date)

Not

Name

Address

Postcode

Profession

only

Phone number including the

dialling code

When did you last see them?

/

/

(approximate date)

Specimen

Name

Address

Po tcode

Profession

Phone number including the

for

use

dialling code

When did you last s th m?

/

/

(approximate dat )

Not

If you need to add more please c

ntinue at Q15 Additional information.

Health condition or disability

only

Approximate start date

Example: Diabetes

May 2010

Specimen

for

We will ask you how your health ond t ons or disabilities affect h w useyou

carry out day-to-day a tivities in the rest of the

rm.

If you need to add more pl ase ontinue at Q15 Additional inf rmation.

Not

only

Specimen

use

Not

for

This includes things like:

•

food preparation such as peeling, chopping or opening packagi g, a d

•

safely cooking or heating food on a cooker hob or in a microwave oven

Tick the boxes that apply to you, then provide more informati

in the

Extra information box.

use

Specimen

Q3a - Do you need to use an aid

Yes

only

or appliance to prepare or

No

cook a simple meal?

Aids and appliances

Som tim s

include things like:

• perching stools,

lightweight pots and

pans, easy grip handles

for

• do they remind or

on utensils, single lever

arm taps and liqu d level

indicators

Q3b – Do you n

d h lp from

Yes

anoth r

rson to pr pare

Not

or cook a sim le m al?

No

By this we m an:

S me imes

motivate you to cook?

• do they plan the task f r

you?

• do they supervise you?

• do they physically help

you?

• do they prepare all your

food for you?

This includes help you

have, and help you need

but don’t get.

• tell us how your condition affects you doing this activity

•

tell us how you manage at the moment and the problems you have when you can't

do this activity

•

tell us how long it takes to prepare and cook food

•

does whether you can do this vary throughout the day? Tell us about good and bad

days

only

•

can you cook using an oven safely? If not, tell us why not

•

tell us about the aids or appliances you need to use to help you prepare and cook

food

•

do you experience any other difficulties, either during or after the activity, ike pain,

breathlessness or tiredness?

•

tell us about the help you need from another person when prepari g f od. This

includes help you have and help you need but don't get

use

Specimen

for

Not

only

Tick the boxes that apply to you, then provide more information in the

Extra information box.

Q4a – Do you need to use an aid

Yes

or appliance to eat and

No

drink?

Aids and appliances

Sometimes

include things like:

use

Specimen

• weighted cups, adapted

cutlery

Q4b – Do you use a feeding tube

Y s

or similar device to eat

No

or drink?

This means things l ke a

So eti es

feeding tube with a rate

for

limiting devi e as a

delivery system or feed

pump.

Q4c – Do you n

Not

d h lp from

Yes

anoth r

rson to at and

No

drink?

By this we mean:

S metimes

• do they remind you to eat

and drink?

• do they supervise you?

• do they physically help

you to eat and drink?

• do they help you manage

a feeding tube?

• tell us how your condition affects you doing this activity

•

tell us how you manage at the moment and the problems you have when you can't

do this activity

•

tell us how long it takes you to complete this activity

•

does whether you can do this vary throughout the day? Tell us about good and bad

days

only

•

do you experience any other difficulties, either during or after the activity, ike pain,

breathlessness or tiredness?

•

tell us about the aids and appliances you need to use to help you eat and drink

•

tell us about the help you need from another person when eati g a d dri ki g. This

includes help you have and help you need but don't get

use

Specimen

for

Not

A home treatment includes things like:

only

• physiotherapy and home dialysis

Tick the boxes that apply to you then provide more information in the Extra

information box.

Q5a – Do you need to use an aid

Yes

or appliance to monitor

No

your health conditions,

take medication or

Sometimes

use

Specimen

manage home

treatments?

For example, using a

Dosette Box for tablets.

Q5b – Do you need help from

Y s

another person to

No

for

monitor your health

conditions, take

So eti es

medication or manage

home treatments?

By this we m an:

• do th y r mind you to

take m dications and

treatm nt?

Not