Blank Pip Form – Fill Out and Use

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

• 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 manage your treatments

•

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 or appliances you need to use to help you monitor our

treatment

•

tell us about the help you need from another person when ma

agi g your

treatments. This includes help you have and help you need but d

't get

use

Specimen

for

Not

only

This doesn't include any difficulties you have getting to the bathroom.

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

information box.

Q6a – Do you need to use an aid

Yes

or appliance to wash and

No

bathe yourself, including

using a bath or shower?

Sometimes

Aids and appliances

Specimen

include things like:

• bath / shower seat,

grab rails

Q6b – Do you need help from

Y s

use

another person to wash

No

and bathe?

By this we mean:

So eti es

• do they physically help

for

you?

• do they tell you when to

wash and bath ?

• do th y wat h ov r you to

make sure you are saf ?

Not

This includ s help you have

and help you n d 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 you to wash and bathe

•

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

•

days

only

do you have difficulty washing particular parts of your body? Which parts?

•

does it take you a long time to wash and bathe?

•

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

breathlessness or tiredness?

•

tell us about the aids or appliances you need to help you wash a d bathe

•

tell us about the help you need from another person when washi g a d bathing.

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

use

Specimen

for

Not

toilet or manage

No

only

Managing incontinence means:

• emptying your bowel and bladder, including if you need a collecting

device such as a bottle, bucket or catheter, and

• cleaning yourself after doing so

This doesn't include difficulties you have getting to the bathroom.

Tick the boxes that apply to you then provide more informati

in the Extra

information box.

use

SpecimenThis includes help you have

Q7a – Do you need to use an aid

Yes

or appliance to use the

incontinence?

Som tim s

Aids and appliances

include things like:

• commodes, raised toilet

seats, bottom wipers,

for

bidets, incontinence pads

or a stoma bag

Q7b – Do you n

d h lp from

Yes

anoth r p rson to use the

toilet or manage

Not

No

incontinenc ?

S me imes

By this we mean:

• do they

hysically help

you?

• tell us how your condition affects you doing this activity

•

tell us how your 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

•

are you incontinent? Tell us in what way and how you manage it

•

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

breathlessness or tiredness?

•

tell us about the aids or appliances you need to use to help you ma

age our toi et

needs

•

tell us about the help you need from another person when ma agi

g your toilet

needs. This includes help you have and help you need but d 't get

use

Specimen

for

Not

Tell us about whether you can dress or undress yourself

This means:

•

putting on and taking off clothes, including shoes and socks

•

knowing when to put on or take off clothes, and

•

being able to select clothes that are appropriate

only

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

information box.

Q8a – Do you need to use an aid

Yes

or appliance to dress or

No

undress?

Aids and appliances

Sometimes

include things like:

• modified buttons, front

use

Specimen

fastening bras, velcro

fastening, shoe aids or an

audio colour detector

Q8b – Do you need help from

Y s

another person to dress

No

or undress?

for

By this we mean:

So eti es

• do they physi ally help

you?

• do they sele t your

cloth s?

• do th y tell you wh

n to

dress and undr ss?

Not

• do th y tell you wh

n to

• 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 dress and undress

•

does whether you can dress or undress yourself vary throughout the day? Tell us

about good and bad

only

•

do you only have difficulty dressing certain parts of your body? Which parts?

•

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

breathlessness or tiredness?

•

tell us about the aids or appliances you need to help with dressi g a d u dressing

•

tell us about the help you need from another person when dressi

g a d

undressing. This includes help you have and help you need but d

't get

use

Specimen

for

Not

information box.

only

Q9a – Do you need to use an

Yes

aid or appliance to

No

communicate with

others?

Sometimes

Aids and appliances

include things like:

• hearing and voice aids

use

• picture symbols, and

Specimen

• assistive computer

technology

Q9b – Do you need help from

Y s

another person to

No

communicate with

others?

So eti es

By this we mean:

for

• do they help you

understand what people

are saying?

• do you have som one

who helps you by

interpr ting sp ch into

sign languag ?

Not

• do th y help you by

s eaking on your behalf?

understanding of what is said to you:

• 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

only

•

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

days

•

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

and distress?

•

tell us about the aids or appliances you need to help you to commu

icate

•

tell us about the help you need from another person when commu

icati g. This

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

use

Specimen

for

Not

This means:

only

•

signs, symbols and words written or printed in your native language, not braille

•

understanding numbers, including dates

• other instructions, such as timetables

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

information box.

Q10a – Do you need to use an

Yes

aid or appliance other

No

than spectacles or

contact lenses to read

Specimen

signs, symbols and

Sometimes

words?

Aids and appliances

include things like

magnifiers.

Q10b – Do you need help from

Yes

use

another person to read

No

or understand signs,

symbols and words?

Sometimes

By this we mean do they

for

read or xplain signs and

symbols to you?

Not

This includ s help you

have and help you n d

but don't get

symbols and written words:

• 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 your difficulties depend on how complicated the signs, symbols and words are, or

how big they are?

•

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

breathlessness or tiredness?

•

tell us about the aids or appliances you need to help y u read

•

tell us about the help you need from another person when readi g. This i cludes help

you have and help you need but don't get

use

Specimen

for

Not

group

•

understand how they're behaving towards you, and

only

•

behave appropriately towards them

It includes both people you know well and people you don't know.

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

information box.

Q11a – Do you need another

Yes

person to help you to

No

mix with other people?

use

Specimen

By this we mean:

Sometimes

• do they encourage you

to mix with other

people?

• do they help you

understand how people

are behaving and how

to behave yourself?

This includes help you

have and help you need

but don't get.

Q11b – Do you find it diffi ult

Yes

to mix with oth r

Not

eo le b cause of

No

severe anxiety or

S me imesfor

distress?

•

tell us about 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

•

do you have behaviours that could put yourself or others at risk?

•

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

•

days

only

do you avoid mixing with other people, some more than others?

•

does it take you a long time to mix with other people?

•

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

anxiety or distress?

•

tell us about help you need from another person when mixi g with other peop e.

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

use

Specimen

for

Not

managing your money. This means: