This form contains 432 fields organized into 35 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Contact phone numbers
Male	Checkbox	Check this box if your sex is male.
Daytime phone number	Text	Enter your daytime phone number (if different from your mobile number), including the dialling code.
Date of birth
Date of birth	Date	Enter your date of birth. Max length: 9 characters
Yes	Checkbox	Check this box if you are a Swiss or EEA national and you were living in the United Kingdom (UK) before 1 January 2021. Fill only if 'Nationality' is Swiss or an EEA national. Depends on: Nationality
Do you have any reports about your illnesses or disabilities?
No	Checkbox	Check this box if you do not have any reports about your illnesses or disabilities. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you have any reports about your illnesses or disabilities (for example, an assessment report or care plan) and can send a copy if available. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Extra information
Additional claim information	Text	Provide any other relevant information you think should be considered in support of your claim.
Fifth Aid/Adaptation Entry
Aid or Adaptation (Fifth Entry)	Text	Enter the name of the fifth aid or adaptation you use. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Prescribed by a health care professional (5th entry)	Checkbox	Check this box if the aid or adaptation you list on the fifth row was prescribed by a health care professional (for example, an occupational therapist). Fill only if 'Aid or Adaptation (Fifth Entry)' is filled. Depends on: Aid or Adaptation (Fifth Entry)
How It Helps You (Fifth Entry)	Text	Describe how the fifth aid or adaptation helps you in daily life. Fill only if 'Aid or Adaptation (Fifth Entry)' is filled. Depends on: Aid or Adaptation (Fifth Entry)
Difficulties Using It (Fifth Entry)	Text	Describe any difficulty you have using the fifth aid or adaptation, including if you need help from another person. Fill only if 'Aid or Adaptation (Fifth Entry)' is filled. Depends on: Aid or Adaptation (Fifth Entry)
Fifth Illness or Disability Details
Fifth illness or disability name	Text	Enter the name of your fifth illness or disability.
Fifth illness or disability duration	Text	Enter how long you have had this fifth illness or disability.
Fifth illness or disability prescribed medicines or treatments	Text	Enter the medicines and/or treatments you have been prescribed for this fifth illness or disability (or write none).
Fifth illness or disability dosage and frequency	Text	Enter the dosage and how often you take each medicine or receive treatment for this fifth illness or disability (or write none).
First Activity and Help Details (at home)
Activity or hobby at home	Text	Enter the hobby, interest, or social/religious activity you do or would like to do at home (for example, listening to music). Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Help needed for activity	Text	Describe what help you need or would need from another person to take part in this activity at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
How often you do this activity	Text	State how often you do or would do this activity (for example, a number of times per week). Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
First Aid/Adaptation Entry
Aid or Adaptation Used	Text	Enter the name of the aid or adaptation you use (for example, magnifier or stairlift). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Tick if you use this aid/adaptation	Checkbox	Check this box for the row where you use the aid or adaptation you have listed. Fill only if 'Aid or Adaptation Used' is filled. Depends on: Aid or Adaptation Used
How This Helps	Text	Describe how this aid or adaptation helps you in your daily life. Fill only if 'Aid or Adaptation Used' is filled. Depends on: Aid or Adaptation Used
Difficulties Using Aid/Adaptation	Text	Describe any difficulty you have using this aid or adaptation or whether you need help from another person to use it. Fill only if 'Aid or Adaptation Used' is filled. Depends on: Aid or Adaptation Used
First Illness or Disability Details
First illness or disability name	Text	Enter the name of the first illness or disability you have.
First illness or disability duration	Text	Describe how long you have had this first illness or disability.
First illness medicines or treatments	Text	List any medicines, treatments, or both that you have been prescribed for this first illness or disability (or enter none).
First illness dosage and frequency	Text	State the dosage and how often you take each medicine or receive treatment for this first illness or disability (or enter none).
First Outings Activity Details
Activity to Do When Going Out	Text	Enter the activity you do or would like to do when you go out. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Help Needed From Another Person	Text	Describe the help you need or would need from another person to do this activity. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
How Often You Do This Activity	Text	State how often you do or would do this activity, including frequency and duration if applicable. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
First Test Details
First Test Date and Type	Text	Enter the date and the type of the first medical test you had for your illness or disability (for example, a treadmill test, peak flow test, hearing test, or sight test). Fill only if 'Yes' is 'Yes'. Depends on: Yes
First Test Results	Text	Enter the results of the first test, including any measurements, stages, or findings you were given. Fill only if 'Yes' is 'Yes'. Depends on: Yes
First Waiting List Surgery Details
Waiting List Start Date	Date	Enter the date you were put on the waiting list for surgery. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Planned Surgery Description	Text	Describe the surgery you are going to have (for example, the type of operation and body part). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Planned Surgery Date	Date	Enter the date the surgery is planned for, if you know it. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fourth Aid/Adaptation Entry
Fourth aid or adaptation used	Text	Enter the name of the fourth aid or adaptation you use (for example, a magnifier or stairlift). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Prescribed by a health care professional (4th entry)	Checkbox	Check this box if the aid or adaptation you list on the fourth line was prescribed by a health care professional (for example, an occupational therapist). Fill only if 'Fourth aid or adaptation used' is filled. Depends on: Fourth aid or adaptation used
How the fourth aid/adaptation helps	Text	Describe how this fourth aid or adaptation helps you in daily life. Fill only if 'Fourth aid or adaptation used' is filled. Depends on: Fourth aid or adaptation used
Difficulty using the fourth aid/adaptation	Text	Describe any difficulty you have using this fourth aid or adaptation, including whether you need help from another person. Fill only if 'Fourth aid or adaptation used' is filled. Depends on: Fourth aid or adaptation used
Fourth Illness or Disability Details
Fourth illness or disability name	Text	Enter the name of the fourth illness or disability you have.
Fourth illness or disability duration	Text	Enter how long you have had this fourth illness or disability.
Fourth illness medicines or treatments	Text	List any medicines, treatments, or both that have been prescribed for this fourth illness or disability (or enter none).
Fourth illness dosage and frequency	Text	Enter the dosage and how often you take each medicine or receive treatment for this fourth illness or disability (or enter none).
General
Surname or family name	Text	Enter your surname or family name.
Your address line 1	Text
Your address line 2	Text
Your address line 3	Text
Postcode	Text	Enter the postcode for your permanent home address.
Normally live in Great Britain: No	Checkbox	Check this box if you do not normally live in Great Britain (England, Scotland, or Wales).
Normally live in Great Britain: Yes	Checkbox	Check this box if you normally live in Great Britain (England, Scotland, or Wales).
Contact me in Welsh (Wales only)	Checkbox	Check this box if you live in Wales and want to be contacted in Welsh in future.
Been abroad more than 4 weeks at a time in last 3 years: No	Checkbox	Check this box if you have not been abroad (outside Great Britain) for more than 4 weeks at a time in the last 3 years.
Been abroad more than 4 weeks at a time in last 3 years: Yes	Checkbox	Check this box if you have been abroad (outside Great Britain) for more than 4 weeks at a time in the last 3 years.
Abroad trip start date	Date	Enter the date you left Great Britain to start the period you were abroad for more than 4 weeks. Fill only if 'Been abroad more than 4 weeks at a time in last 3 years: Yes' is 'Yes'. Depends on: Been abroad more than 4 weeks at a time in last 3 years: Yes
Abroad trip end date	Date	Enter the date you returned to Great Britain at the end of the period you were abroad for more than 4 weeks. Fill only if 'Been abroad more than 4 weeks at a time in last 3 years: Yes' is 'Yes'. Depends on: Been abroad more than 4 weeks at a time in last 3 years: Yes
Where you went	Text	State the country and place(s) you travelled to during the time you were abroad. Fill only if 'Been abroad more than 4 weeks at a time in last 3 years: Yes' is 'Yes'. Depends on: Been abroad more than 4 weeks at a time in last 3 years: Yes
Reason for going abroad	Text	Explain why you went abroad for this period (for example, holiday, work, visiting family, medical treatment). Fill only if 'Been abroad more than 4 weeks at a time in last 3 years: Yes' is 'Yes'. Depends on: Been abroad more than 4 weeks at a time in last 3 years: Yes
Getting benefits from an EEA state or Switzerland: No	Checkbox	Check this box if neither you nor your wife/husband/civil partner is getting any pensions or benefits from an EEA state or Switzerland.
Getting benefits from an EEA state or Switzerland: Yes	Checkbox	Check this box if you or your wife/husband/civil partner is getting any pensions or benefits from an EEA state or Switzerland.
Getting benefits from an EEA state or Switzerland: Do not know	Checkbox	Check this box if you are not sure whether you or your wife/husband/civil partner is getting pensions or benefits from an EEA state or Switzerland.
Working/paying insurance in an EEA state or Switzerland: No	Checkbox	Check this box if neither you nor your wife/husband/civil partner is working in or paying work-related insurance to an EEA state or Switzerland.
Working/paying insurance in an EEA state or Switzerland: Yes	Checkbox	Check this box if you or your wife/husband/civil partner is working in or paying work-related insurance to an EEA state or Switzerland.
Working/paying insurance in an EEA state or Switzerland: Do not know	Checkbox	Check this box if you are not sure whether you or your wife/husband/civil partner is working in or paying work-related insurance to an EEA state or Switzerland.
Moved from Scotland to live in England or Wales: No	Checkbox	Check this box if you have not moved from Scotland to live in England or Wales.
Moved from Scotland to live in England or Wales: Yes	Checkbox	Check this box if you have moved from Scotland to live in England or Wales.
Date moved to England or Wales	Date	Enter the date you moved from Scotland to live in England or Wales. Fill only if 'Moved from Scotland to live in England or Wales: Yes' is 'Yes'. Depends on: Moved from Scotland to live in England or Wales: Yes
Claiming/claimed Pension Age Disability Payment: No	Checkbox	Check this box if you are not getting and have not made a claim for Pension Age Disability Payment.
Claiming/claimed Pension Age Disability Payment: Yes	Checkbox	Check this box if you are getting or have made a claim for Pension Age Disability Payment.
No (not signing for someone else)	Checkbox	Check this box if you are not signing the form on behalf of someone else.
Yes (signing for someone else)	Checkbox	Check this box if you are completing and signing the form on behalf of another person.
Deputy	Checkbox	Check this box if you are acting as the person’s Deputy. Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
Tutor (under Scottish law)	Checkbox	Check this box if you are a Tutor under Scottish law for the person you are claiming for. Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
Curator bonis or judicial factor (under Scottish law)	Checkbox	Check this box if you are a curator bonis or judicial factor under Scottish law for the person you are claiming for. Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
Yes (have an online account)	Checkbox	Check this box if you have an online account for the Power of Attorney for Property and Finance. Fill only if 'Power of Attorney for Property and Finance' is 'Yes'. Depends on: Power of Attorney for Property and Finance
No (do not have an online account)	Checkbox	Check this box if you do not have an online account for the Power of Attorney for Property and Finance. Fill only if 'Power of Attorney for Property and Finance' is 'No'. Depends on: Power of Attorney for Property and Finance
Corporate Acting Body / Corporate Appointee	Checkbox	Check this box if you are acting for the person as a Corporate Acting Body or Corporate Appointee (for example, an organisation appointed to act on their behalf). Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
Power of Attorney for Property and Finance	Checkbox	Check this box if you hold Power of Attorney for Property and Finance for the person you are claiming for. Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
Claiming under special rules (near end of life)	Checkbox	Check this box if you are claiming for the person under the special rules for people nearing the end of life. Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
DWP appointee	Checkbox	Check this box if you are an appointee appointed by the Department for Work and Pensions to deal with the person’s benefits. Fill only if 'Yes (signing for someone else)' is 'Yes'. Depends on: Yes (signing for someone else)
Organisation name	Text	Enter the full name of the organisation you represent that is acting on behalf of the person the form is for. Fill only if 'Corporate Acting Body / Corporate Appointee' is 'Yes'. Depends on: Corporate Acting Body / Corporate Appointee
I want to be appointed to act on their behalf	Checkbox	Check this box if you are applying to be appointed to act on behalf of the person you are claiming for. Fill only if 'Are you signing the form for someone else?' is 'Yes'. Depends on: Yes (signing for someone else)
Full name	Text	Enter your full name. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
National Insurance number	Text	Enter your National Insurance number. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Max length: 9 characters Depends on: I want to be appointed to act on their behalf
Date of birth	Date	Enter your date of birth. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
Address line 1	Text	Enter the first line of your full address (e.g., house number and street). Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
Address line 2	Text	Enter the second line of your address (e.g., apartment, building, or district), if applicable. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
Address line 3	Text	Enter the third line of your address (e.g., town/city or county), if applicable. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
Postcode	Text	Enter your postcode. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
Daytime phone number	Text	Enter your daytime phone number. Fill only if 'I want to be appointed to act on their behalf' is 'Yes'. Depends on: I want to be appointed to act on their behalf
No (Q17)	Checkbox	Check this box if, apart from your GP, you have not seen anyone about your illnesses or disabilities in the last 12 months.
Yes (Q17)	Checkbox	Check this box if, apart from your GP, you have seen someone about your illnesses or disabilities in the last 12 months.
Healthcare professional title and name	Text	Enter the title and full name of the healthcare professional you have seen about your illnesses or disabilities. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Healthcare professional profession/specialist area	Text	Enter the healthcare professional's job title or specialist area (for example, consultant, physiotherapist, occupational therapist). Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Healthcare professional address line 1	Text	Enter the first line of the full address where you see this healthcare professional (such as the health centre or hospital). Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Healthcare professional address line 2	Text	Enter the second line of the full address where you see this healthcare professional. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Healthcare professional address line 3	Text	Enter the third line of the full address where you see this healthcare professional. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Healthcare professional postcode	Text	Enter the postcode for the address where you see this healthcare professional. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Healthcare professional phone number	Text	Enter the healthcare professional's phone number, including the dialling code. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Hospital record number	Text	Enter your hospital record number for this service, as shown on your appointment card or letter. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Illnesses/disabilities discussed	Text	Describe which of your illnesses or disabilities you see this healthcare professional about. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
How often you see them	Text	State how often you usually see this healthcare professional because of your illnesses or disabilities. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
Date last seen	Date	Enter the date when you last saw this healthcare professional because of your illnesses or disabilities. Fill only if 'Yes (Q17)' is 'Yes'. Depends on: Yes (Q17)
No (Q18)	Checkbox	Check this box if no one else helps you because of your illnesses or disabilities.
Yes (Q18)	Checkbox	Check this box if someone else helps you because of your illnesses or disabilities (for example a carer, support worker, nurse, friend, neighbour, or family member).
Helper name	Text	Enter the full name of the person who helps you because of your illnesses or disabilities. Fill only if 'Yes (Q18)' is 'Yes'. Depends on: Yes (Q18)
Helper full address	Text	Enter the helper's full address. Fill only if 'Yes (Q18)' is 'Yes'. Depends on: Yes (Q18)
Full address of where you see the person you have seen about your illnesses or disabilities in the last 12 months (not your GP). For example, the address of the health centre or hospital, address line 1	Text
Full address of where you see the person you have seen about your illnesses or disabilities in the last 12 months (not your GP). For example, the address of the health centre or hospital, address line 2	Text
Full address of where you see the person you have seen about your illnesses or disabilities in the last 12 months (not your GP). For example, the address of the health centre or hospital, address line 3	Text
Helper postcode	Text	Enter the postcode for the helper's address. Fill only if 'Yes (Q18)' is 'Yes'. Depends on: Yes (Q18)
Helper phone number	Text	Enter the helper's phone number, including the dialling code. Fill only if 'Yes (Q18)' is 'Yes'. Depends on: Yes (Q18)
Help you get from them	Text	Describe what help you get from this person. Fill only if 'Yes (Q18)' is 'Yes'. Depends on: Yes (Q18)
Relationship to you	Text	Enter the other person’s relationship to you (for example, friend, relative, carer, or support worker). Fill only if 'Does anyone else help you because of your illnesses or disabilities?' is 'Yes'. Depends on: Yes (Q18)
How often you see them	Text	Describe how frequently you see this person (for example, daily, weekly, monthly, or occasionally). Fill only if 'Does anyone else help you because of your illnesses or disabilities?' is 'Yes'. Depends on: Yes (Q18)
GP name or surgery/health centre	Text	Enter your GP’s name, or if you do not know it, the name of the surgery or health centre.
GP address line 1	Text	Enter the first line of your GP’s full address (for example, building name/number and street).
Full address of your GP or surgery , address line 1	Text
Full address of your GP or surgery , address line 2	Text
GP address line 2	Text	Enter the remaining part of your GP’s address (for example, area, town/city, or county).
GP postcode	Text	Enter the postcode for your GP’s address.
GP phone number	Text	Enter your GP’s phone number, including the dialling code.
Date last seen by GP for your illnesses/disabilities	Date	Enter the date you last saw your GP because of your illnesses or disabilities.
No	Checkbox	Check this box if you do not agree to DWP contacting your GP or other people/organisations involved with you for information about your claim.
Yes	Checkbox	Check this box if you agree to DWP contacting your GP or other people/organisations involved with you for information (including medical information) about your claim.
Consent date	Date	Enter the date you signed the consent section.
No	Checkbox	Check this box if you are not on a waiting list for surgery. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you are currently on a waiting list for surgery. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
No	Checkbox	Check this box if you have not had any tests for your illnesses or disabilities. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you have had any tests for your illnesses or disabilities and will provide details about them. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Type of accommodation	Text	Enter the type of accommodation you live in (for example, house, bungalow, flat, supported housing, residential care home, nursing home, or other). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Toilet location: Upstairs	Checkbox	Check this box if the toilet in your home is upstairs. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Toilet location: Downstairs	Checkbox	Check this box if the toilet in your home is downstairs. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Toilet location: Other	Checkbox	Check this box if the toilet in your home is located somewhere other than upstairs or downstairs (and provide details where asked). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Toilet location in home (other details)	Text	Describe where the toilet is in your home if it is not simply upstairs or downstairs. Fill only if 'Toilet location: Other' is 'Yes'. Depends on: Toilet location: Other
Sleeping location: Upstairs	Checkbox	Check this box if you sleep upstairs in your home. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Sleeping location: Downstairs	Checkbox	Check this box if you sleep downstairs in your home. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Sleeping location: Other	Checkbox	Check this box if you sleep somewhere other than upstairs or downstairs in your home (and provide details where asked). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Sleeping location in home (other details)	Text	Describe where you sleep in your home if it is not simply upstairs or downstairs. Fill only if 'Sleeping location: Other' is 'Yes'. Depends on: Sleeping location: Other
Date care needs started	Date	Enter the date when you first started needing the help described in this claim. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
No	Checkbox	Check this box if you do not usually have difficulty and do not need help getting out of bed in the morning or getting into bed at night. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you usually have difficulty or need help getting out of bed in the morning or getting into bed at night. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
I have difficulty: getting into bed	Checkbox	Check this box if you usually have difficulty getting into bed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I have difficulty: getting out of bed	Checkbox	Check this box if you usually have difficulty getting out of bed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I need help: getting into bed	Checkbox	Check this box if you usually need someone’s help to get into bed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I need help: getting out of bed	Checkbox	Check this box if you usually need someone’s help to get out of bed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Need encouragement: to get out of bed in the morning	Checkbox	Check this box if you usually need encouragement to get out of bed in the morning due to difficulty concentrating or motivating yourself. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Need encouragement: to go to bed at night	Checkbox	Check this box if you usually need encouragement to go to bed at night due to difficulty concentrating or motivating yourself. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not have anything else to tell about the difficulty you have or the help you need getting in or out of bed. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you have additional information to tell about the difficulty you have or the help you need getting in or out of bed. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
More details about getting in or out of bed	Text	Provide any additional information about the difficulty you have or the help you need with getting into bed or getting out of bed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not usually have difficulty and do not need help with your toilet needs. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you usually have difficulty or need help with your toilet needs. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Toilet needs difficulty frequency (1)	Text	Enter how many times each day you have difficulty managing your toilet needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Toilet needs difficulty frequency (2)	Text	Enter how many times each day you have difficulty managing your toilet needs for this second example/entry. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incontinence needs difficulty frequency	Text	Enter how many times each day you have difficulty managing your incontinence needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Help needed with toilet needs frequency	Text	Enter how many times each day you need help with your toilet needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Help needed with incontinence needs frequency	Text	Enter how many times each day you need help with your incontinence needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Encouragement needed for toilet needs frequency	Text	Enter how many times each day you need encouragement because you have difficulty concentrating or motivating yourself to manage your toilet needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Encouragement needed for incontinence needs frequency	Text	Enter how many times each day you need encouragement because you have difficulty concentrating or motivating yourself to manage your incontinence needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not have anything else to tell about the difficulty you have or the help you need with your toilet needs. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you have something else to tell about the difficulty you have or the help you need with your toilet needs. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Additional details about toilet needs difficulties/help	Text	Provide any additional information you want to share about the difficulties you have or the help you need with your toilet needs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not usually have difficulty and do not need help with washing, bathing, showering, or looking after your appearance. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you usually have difficulty or need help with washing, bathing, showering, or looking after your appearance. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Difficulty looking after appearance frequency	Text	Enter how many times each day you have difficulty washing, bathing, showering, or looking after your appearance. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Bath Entry/Exit Difficulty Frequency	Text	Enter how often each day you have difficulty getting in and out of the bath. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Washing/Drying or Personal Hygiene Difficulty Frequency	Text	Enter how often each day you have difficulty washing and drying yourself or looking after your personal hygiene. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Shower Use Difficulty Frequency	Text	Enter how often each day you have difficulty using a shower. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Help Needed for Appearance Frequency	Text	Enter how often each day you need help looking after your appearance. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Help Needed for Bath Entry/Exit Frequency	Text	Enter how often each day you need help getting in and out of the bath. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Help Needed for Washing/Drying or Personal Hygiene Frequency	Text	Enter how often each day you need help washing and drying yourself or looking after your personal hygiene. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Help Needed Using the Shower Frequency	Text	Enter how often each day you need help using the shower. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Encouragement Needed for Appearance Frequency	Text	Enter how often each day you need encouragement to look after your appearance due to difficulty concentrating or motivating yourself. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Encouragement/Reminders Needed for Personal Hygiene Frequency	Text	Enter how often each day you need encouraging or reminding about washing, bathing, showering, drying, or looking after your personal hygiene due to difficulty concentrating or motivating yourself. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
No (nothing else to tell us)	Checkbox	Check this box if you do not have anything else to add about the difficulty you have or the help you need with washing, bathing, showering, looking after your appearance, or personal hygiene. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Yes (I have more to tell you)	Checkbox	Check this box if you have additional information to provide about the difficulty you have or the help you need with washing, bathing, showering, looking after your appearance, or personal hygiene. Fill only if 'Do you usually have difficulty or do you need help with washing, bathing, showering or looking after your appearance?' is 'Yes'. Depends on: Yes
Additional Details About Hygiene/Appearance Difficulties	Text	Provide any additional details about the difficulties you have or the help you need with washing, bathing, showering, or looking after your appearance or personal hygiene. Fill only if 'Yes (I have more to tell you)' is 'Yes'. Depends on: Yes (I have more to tell you)
Q32: No (no difficulty/need help dressing or undressing)	Checkbox	Check this box if you do not usually have difficulty and do not need help with dressing or undressing.
Q32: Yes (I have difficulty/need help dressing or undressing)	Checkbox	Check this box if you usually have difficulty or need help with dressing or undressing.
Dressing (Putting On/Fastening) Difficulty Frequency	Text	Enter how often each day you have difficulty putting on or fastening clothes or footwear. Fill only if 'Q32: Yes (I have difficulty/need help dressing or undressing)' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Undressing (Taking Off) Difficulty Frequency	Text	Enter how often each day you have difficulty taking off clothes or footwear. Fill only if 'Q32: Yes (I have difficulty/need help dressing or undressing)' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Frequency of difficulty choosing appropriate clothes	Text	Enter how often each day you have difficulty choosing the appropriate clothes. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Frequency of needing help putting on or fastening clothes/footwear	Text	Enter how often each day you need help putting on or fastening clothes or footwear. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Frequency of needing help taking off clothes/footwear	Text	Enter how often each day you need help taking off clothes or footwear. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Frequency of needing help choosing appropriate clothes	Text	Enter how often each day you need help choosing the appropriate clothes. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Frequency of needing encouragement to get dressed/undressed	Text	Enter how often each day you need encouraging to get dressed or undressed due to difficulty concentrating or motivating yourself. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Frequency of needing reminders to change clothes	Text	Enter how often each day you need reminding to change your clothes due to difficulty concentrating or motivating yourself. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
No	Checkbox	Check this box if you do not have anything else to tell us about the difficulty you have or the help you need dressing or undressing. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Yes	Checkbox	Check this box if you do have something else to tell us about the difficulty you have or the help you need dressing or undressing. Fill only if 'Do you usually have difficulty or do you need help with dressing or undressing?' is 'Yes'. Depends on: Q32: Yes (I have difficulty/need help dressing or undressing)
Additional details about dressing/undressing difficulty or help needed	Text	Provide any other information about the difficulty you have or the help you need with dressing or undressing (for example breathlessness, pain, or taking a long time). Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not usually have difficulty and do not need help with moving around indoors.
Yes	Checkbox	Check this box if you usually have difficulty or need help with moving around indoors.
walking around indoors	Checkbox	Check this box if you have difficulty walking around indoors. Fill only if 'Yes' is 'Yes'. Depends on: Yes
going up or down stairs	Checkbox	Check this box if you have difficulty going up or down stairs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
getting in or out of a chair	Checkbox	Check this box if you have difficulty getting in or out of a chair. Fill only if 'Yes' is 'Yes'. Depends on: Yes
transferring to and from a wheelchair	Checkbox	Check this box if you have difficulty transferring to and from a wheelchair. Fill only if 'Yes' is 'Yes'. Depends on: Yes
walking around indoors	Checkbox	Check this box if you need help walking around indoors. Fill only if 'Yes' is 'Yes'. Depends on: Yes
going up or down stairs	Checkbox	Check this box if you need help going up or down stairs. Fill only if 'Yes' is 'Yes'. Depends on: Yes
getting in or out of a chair	Checkbox	Check this box if you need help getting in or out of a chair. Fill only if 'Yes' is 'Yes'. Depends on: Yes
transferring to and from a wheelchair	Checkbox	Check this box if you need help transferring to and from a wheelchair. Fill only if 'Yes' is 'Yes'. Depends on: Yes
encouraging or reminding to move around indoors	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouraging or reminding to move around indoors. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not have anything else to tell us about the difficulty you have or the help you need with moving around indoors. Fill only if 'Do you usually have difficulty or do you need help with moving around indoors?' is 'Yes'. Depends on: Yes
Yes	Checkbox	Check this box if you do have something else to tell us about the difficulty you have or the help you need with moving around indoors. Fill only if 'Do you usually have difficulty or do you need help with moving around indoors?' is 'Yes'. Depends on: Yes
Indoor mobility details	Text	Describe anything else you want to tell us about difficulties you have or help you need when moving around indoors. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not fall or stumble because of your illnesses or disabilities.
Fall	Checkbox	Check this box if you fall because of your illnesses or disabilities.
Stumble	Checkbox	Check this box if you stumble because of your illnesses or disabilities.
What happens when you fall or stumble	Text	Explain what happens when you fall or stumble, including why it happens and whether you hurt yourself. Fill only if 'Fall', 'Stumble' is 'Yes' for any fields selection. Depends on: Fall, Stumble
No	Checkbox	Check this box if you have not been referred to a Falls Clinic.
Yes	Checkbox	Check this box if you have been referred to a Falls Clinic.
No	Checkbox	Check this box if you do not need help from someone else to get up after a fall.
Yes	Checkbox	Check this box if you do need help from someone else to get up after a fall.
Help needed after a fall	Text	Describe any difficulty you have getting up after a fall and the help you need from someone else. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Date of last fall	Text	State when you last fell (give an approximate time if you do not know the exact date). Fill only if 'Fall' is 'Yes'. Depends on: Fall
Date of last stumble	Text	State when you last stumbled (give an approximate time if you do not know the exact date). Fill only if 'Stumble' is 'Yes'. Depends on: Stumble
Falls in last month	Text	Enter roughly how many times you have fallen in the last month. Fill only if 'Fall' is 'Yes'. Depends on: Fall
Falls in last year	Text	Enter roughly how many times you have fallen in the last year. Fill only if 'Fall' is 'Yes'. Depends on: Fall
Stumbles in last month	Text	Enter roughly how many times you have stumbled in the last month. Fill only if 'Do you fall or stumble because of your illnesses or disabilities?' is 'Stumble'. Depends on: Stumble
Stumbles in last year	Text	Enter roughly how many times you have stumbled in the last year. Fill only if 'Do you fall or stumble because of your illnesses or disabilities?' is 'Stumble'. Depends on: Stumble
No	Checkbox	Check this box if you do not usually have difficulty and do not need help with cutting up food, eating, or drinking.
Yes	Checkbox	Check this box if you usually have difficulty or need help with cutting up food, eating, or drinking.
Eating or drinking difficulty frequency	Text	Describe how often each day you have difficulty eating or drinking. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Cutting up food difficulty frequency	Text	Describe how often each day you have difficulty cutting up food on your plate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Help needed eating or drinking frequency	Text	Describe how often each day you need help eating or drinking. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Help needed cutting up food frequency	Text	Describe how often each day you need help cutting up food on your plate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Encouragement/reminders to eat or drink frequency	Text	Describe how often each day you need encouraging or reminding to eat or drink due to difficulty concentrating or motivating yourself. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if there is nothing else you want to tell about the difficulty you have or the help you need with cutting up food, eating, or drinking.
Yes	Checkbox	Check this box if there is something else you want to tell about the difficulty you have or the help you need with cutting up food, eating, or drinking.
Additional details about eating/drinking or cutting up food	Text	Provide any additional information about the difficulty you have or the help you need with cutting up food, eating, or drinking. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not usually have difficulty and do not need help with taking your medicines or with your medical treatment.
Yes	Checkbox	Check this box if you usually have difficulty or need help with taking your medicines or with your medical treatment.
Medication difficulty frequency	Text	Describe how often each day you have difficulty taking your medication. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Treatment or therapy difficulty frequency	Text	Describe how often each day you have difficulty with your treatment or therapy. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Medication help frequency per day	Text	Enter how many times each day you need help taking your medication. Fill only if 'Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?' is 'Yes'. Depends on: Yes
Treatment/therapy help frequency per day	Text	Enter how many times each day you need help with your treatment or therapy. Fill only if 'Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?' is 'Yes'. Depends on: Yes
Medication encouragement/reminder frequency per day	Text	Enter how many times each day you need encouraging or reminding to take your medication because you have difficulty concentrating or motivating yourself. Fill only if 'Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?' is 'Yes'. Depends on: Yes
Treatment/therapy encouragement/reminder frequency per day	Text	Enter how many times each day you need encouraging or reminding about your treatment or therapy because you have difficulty concentrating or motivating yourself. Fill only if 'Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?' is 'Yes'. Depends on: Yes
No (nothing else to tell us)	Checkbox	Check this box if you do not have anything else to tell us about your difficulty or the help you need taking medication or with medical treatment. Fill only if 'Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?' is 'Yes'. Depends on: Yes
Yes (tell us about this)	Checkbox	Check this box if you do have something else to tell us about your difficulty or the help you need taking medication or with medical treatment. Fill only if 'Do you usually have difficulty or do you need help with taking your medicines or with your medical treatment?' is 'Yes'. Depends on: Yes
No (do you need help communicating?)	Checkbox	Check this box if you do not usually need help from another person to communicate with other people.
Yes (do you need help communicating?)	Checkbox	Check this box if you usually need help from another person to communicate with other people.
Difficulty: understanding people I do not know well	Checkbox	Check this box if you have difficulty understanding people you do not know well when communicating. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Difficulty: being understood by people who do not know me well	Checkbox	Check this box if you have difficulty being understood by people who do not know you well. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Difficulty: concentrating or remembering things	Checkbox	Check this box if you have difficulty concentrating or remembering things that affects communication. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Difficulty: answering or using the phone	Checkbox	Check this box if you have difficulty answering the phone or using the phone. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Difficulty: reading letters, filling in forms, replying to mail	Checkbox	Check this box if you have difficulty reading letters, filling in forms, or replying to mail. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Difficulty: asking for help when I need it	Checkbox	Check this box if you have difficulty asking for help when you need it. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Need help: understanding people I do not know well	Checkbox	Check this box if you need another person’s help to understand people you do not know well. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Need help: being understood by people who do not know me well	Checkbox	Check this box if you need another person’s help so that people who do not know you well can understand you. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Additional details about medication or treatment help	Text	Provide any additional information about the difficulties you have or the help you need with taking medication or with medical treatment. Fill only if 'Yes (tell us about this)' is 'Yes'. Depends on: Yes (tell us about this)
Need help: concentrating or remembering things	Checkbox	Check this box if you need another person’s help due to problems concentrating or remembering things. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Need help: answering or using the phone	Checkbox	Check this box if you need another person’s help to answer the phone or use the phone. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Need help: reading letters, filling in forms, replying to mail	Checkbox	Check this box if you need another person’s help reading letters, filling in forms, or replying to mail. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
Need help: asking for help when I need it	Checkbox	Check this box if you need another person’s help to ask for help when you need it. Fill only if 'Yes (do you need help communicating?)' is 'Yes'. Depends on: Yes (do you need help communicating?)
No (nothing else to tell about communication help)	Checkbox	Check this box if you do not have anything else to tell them about difficulties you have, or help you need from another person, to communicate with other people. Fill only if 'Do you usually need help from another person to communicate with other people?' is 'Yes'. Depends on: Yes (do you need help communicating?)
Yes (more to tell about communication help)	Checkbox	Check this box if you do have more to tell them about difficulties you have, or help you need from another person, to communicate with other people (for example using BSL). Fill only if 'Do you usually need help from another person to communicate with other people?' is 'Yes'. Depends on: Yes (do you need help communicating?)
Additional communication help details	Text	Describe any other difficulties you have, or help you need from another person, to communicate with other people (for example, using British Sign Language). Fill only if 'Yes (more to tell about communication help)' is 'Yes'. Depends on: Yes (more to tell about communication help)
Days per week needing help (questions 28–37)	Text	Enter how many days per week you have the difficulties or need help with the care needs you described in questions 28 to 37. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
No (help needed to take part in hobbies/activities)	Checkbox	Check this box if you do not usually need help from another person to actively take part in hobbies, interests, or social or religious activities. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes (help needed to take part in hobbies/activities)	Checkbox	Check this box if you usually need help from another person to actively take part in hobbies, interests, or social or religious activities. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
No	Checkbox	Check this box if you do not usually need someone to keep an eye on you (you do not need supervision). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you usually need someone to keep an eye on you (you need supervision). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
To prevent danger to myself or others	Checkbox	Check this box if you need supervision to stop you from putting yourself or other people in danger. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I am not aware of common dangers	Checkbox	Check this box if you need supervision because you are not aware of everyday/common dangers. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I am at risk of neglecting myself	Checkbox	Check this box if you need supervision because you may fail to look after your own basic needs or self-care. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I am at risk of harming myself	Checkbox	Check this box if you need supervision because there is a risk you may harm yourself. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may wander	Checkbox	Check this box if you need supervision because you may wander off or leave without it being safe. Fill only if 'Yes' is 'Yes'. Depends on: Yes
To discourage antisocial or aggressive behaviour	Checkbox	Check this box if you need supervision to prevent or reduce antisocial or aggressive behaviour. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may have fits, dizzy spells or blackouts	Checkbox	Check this box if you need supervision because you may have fits, dizziness, or blackouts that could make you unsafe. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may get confused	Checkbox	Check this box if you need supervision because you may become confused and this could put you at risk. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may hear voices or experience thoughts that disrupt my thinking	Checkbox	Check this box if you need supervision because hearing voices or disruptive thoughts may affect your safety or ability to cope. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Safe time left alone	Text	Enter how long you can be safely left on your own at one time without supervision. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not want to tell us anything else about the supervision you need from another person. Fill only if 'Do you usually need someone to keep an eye on you?' is 'Yes'. Depends on: Yes
Yes	Checkbox	Check this box if you want to tell us something else about the supervision you need from another person. Fill only if 'Do you usually need someone to keep an eye on you?' is 'Yes'. Depends on: Yes
Additional supervision details	Text	Describe anything else you want to tell us about the supervision you need from another person. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Days per week needing someone to keep an eye on you	Text	Enter how many days each week you need someone to keep an eye on you. Fill only if 'Do you usually need someone to keep an eye on you?' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not usually have difficulty or need help during the night.
Yes	Checkbox	Check this box if you usually have difficulty or need help during the night.
1	Checkbox	Check this box if, each night, you need help turning over or changing position in bed 1 time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
2	Checkbox	Check this box if, each night, you need help turning over or changing position in bed 2 times. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3+	Checkbox	Check this box if, each night, you need help turning over or changing position in bed 3 or more times. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Minutes per time for help turning over/changing position	Text	Enter how many minutes each time you need help turning over or changing position in bed during the night. Fill only if 'Yes' is 'Yes'. Depends on: Yes
1	Checkbox	Check this box if, each night, you have difficulty or need help sleeping comfortably 1 time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
2	Checkbox	Check this box if, each night, you have difficulty or need help sleeping comfortably 2 times. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3+	Checkbox	Check this box if, each night, you have difficulty or need help sleeping comfortably 3 or more times. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Minutes per time for help sleeping comfortably	Text	Enter how many minutes each time you need help sleeping comfortably during the night. Fill only if 'Yes' is 'Yes'. Depends on: Yes
1	Checkbox	Check this box if, each night, you have difficulty or need help with your toilet needs 1 time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
2	Checkbox	Check this box if, each night, you have difficulty or need help with your toilet needs 2 times. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3+	Checkbox	Check this box if, each night, you have difficulty or need help with your toilet needs 3 or more times. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Minutes per time for help with toilet needs at night	Text	Enter how many minutes each time you need help with your toilet needs during the night. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incontinence needs: 2	Checkbox	Check this box if you have difficulty or need help with your incontinence needs 2 times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Incontinence needs: 3+	Checkbox	Check this box if you have difficulty or need help with your incontinence needs 3 or more times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Incontinence needs: 1	Checkbox	Check this box if you have difficulty or need help with your incontinence needs 1 time each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Incontinence help minutes per time	Text	Enter how many minutes you typically need help each time during the night with your incontinence needs. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Taking my medication: 1	Checkbox	Check this box if you have difficulty or need help taking your medication 1 time each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Taking my medication: 2	Checkbox	Check this box if you have difficulty or need help taking your medication 2 times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Taking my medication: 3+	Checkbox	Check this box if you have difficulty or need help taking your medication 3 or more times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Medication help minutes per time	Text	Enter how many minutes you typically need help each time during the night with taking your medication. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Treatment or therapy: 1	Checkbox	Check this box if you have difficulty or need help with treatment or therapy 1 time each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Treatment or therapy: 2	Checkbox	Check this box if you have difficulty or need help with treatment or therapy 2 times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Treatment or therapy: 3+	Checkbox	Check this box if you have difficulty or need help with treatment or therapy 3 or more times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Treatment or therapy help minutes per time	Text	Enter how many minutes you typically need help each time during the night with treatment or therapy. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Need encouragement/reminding about toilet or incontinence needs: 1	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouragement or reminding about your toilet or incontinence needs 1 time each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Need encouragement/reminding about toilet or incontinence needs: 2	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouragement or reminding about your toilet or incontinence needs 2 times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Need encouragement/reminding about toilet or incontinence needs: 3+	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouragement or reminding about your toilet or incontinence needs 3 or more times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Toilet/incontinence reminding minutes per time	Text	Enter how many minutes you typically need each time during the night for encouragement or reminders about your toilet or incontinence needs. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Need encouraging/reminding about medication or medical treatment: 1	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouraging or reminding about medication or medical treatment 1 time each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Need encouraging/reminding about medication or medical treatment: 2	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouraging or reminding about medication or medical treatment 2 times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Need encouraging/reminding about medication or medical treatment: 3+	Checkbox	Check this box if you have difficulty concentrating or motivating yourself and need encouraging or reminding about medication or medical treatment 3 or more times each night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Medication/treatment reminding minutes per time	Text	Enter how many minutes you typically need each time during the night for encouragement or reminders about medication or medical treatment. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Anything else to tell us about night-time difficulty/help needed: No	Checkbox	Check this box if there is nothing else you want to tell about the difficulty you have or the help you need during the night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Anything else to tell us about night-time difficulty/help needed: Yes	Checkbox	Check this box if there is something else you want to tell about the difficulty you have or the help you need during the night. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
Additional night-time care details	Text	Provide any additional details about the difficulties you have or the help you need during the night. Fill only if 'Anything else to tell us about night-time difficulty/help needed: Yes' is 'Yes'. Depends on: Anything else to tell us about night-time difficulty/help needed: Yes
Nights per week needing help	Text	Enter how many nights per week you have difficulty or need help with your care needs. Fill only if 'Do you usually have difficulty or need help during the night?' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if you do not usually need someone to watch over you. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Yes	Checkbox	Check this box if you usually need someone to watch over you. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
To prevent danger to myself or others	Checkbox	Check this box if you need someone to watch over you to prevent danger to yourself or other people. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I am not aware of common dangers	Checkbox	Check this box if you need someone to watch over you because you are not aware of common dangers. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I am at risk of harming myself	Checkbox	Check this box if you need someone to watch over you because you may harm yourself. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may wander	Checkbox	Check this box if you need someone to watch over you because you may wander. Fill only if 'Yes' is 'Yes'. Depends on: Yes
To discourage antisocial or aggressive behaviour	Checkbox	Check this box if you need someone to watch over you to discourage antisocial or aggressive behaviour. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may get confused	Checkbox	Check this box if you need someone to watch over you because you may become confused. Fill only if 'Yes' is 'Yes'. Depends on: Yes
I may hear voices or experience thoughts that disrupt my thinking	Checkbox	Check this box if you need someone to watch over you because you may hear voices or have disruptive thoughts. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Times per Night Watch Required	Text	Enter how many times in a typical night another person needs to be awake to watch over you. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Average Awake Duration at Night	Text	Describe how long on average another person needs to stay awake to watch over you at night. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Checkbox	Check this box if there is nothing else you want to tell about why you need someone to watch over you. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Yes	Checkbox	Check this box if you have additional information to tell about why you need someone to watch over you. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Additional Details About Need for Supervision	Text	Provide any additional information explaining why you need someone to watch over you. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Nights per Week Watch Required	Text	Enter how many nights per week you need someone to watch over you. Fill only if 'Yes' is 'Yes'. Depends on: Yes
In hospital/care home now: No	Checkbox	Check this box if you are not currently in hospital, a care home, or a similar place.
In hospital/care home now: Yes	Checkbox	Check this box if you are currently in hospital, a care home, or a similar place.
Date went into hospital/care home (current stay)	Date	Enter the date you went into the hospital, care home, or similar place where you are staying now. Fill only if 'In hospital/care home now: Yes' is 'Yes'. Depends on: In hospital/care home now: Yes
Authority contributes to costs of stay: No	Checkbox	Check this box if no local/health/education authority or government department gives you (or the place you stay) any money towards the costs of your stay.
Authority contributes to costs of stay: Yes	Checkbox	Check this box if a local/health/education authority or a government department gives you (or the place you stay) money towards the costs of your stay.
Reason for going into hospital (current stay)	Text	Describe why you went into hospital, if you are currently in hospital. Fill only if 'In hospital/care home now: Yes' is 'Yes'. Depends on: In hospital/care home now: Yes
Current place name/address (line 1)	Text	Enter the full name of the hospital/care home (or similar place) and the first line of its address where you are staying. Fill only if 'In hospital/care home now: Yes' is 'Yes'. Depends on: In hospital/care home now: Yes
About time spent in hospital, a care home or a similar place - Tell us the full name and address of the place where you were staying, address line 1	Text
About time spent in hospital, a care home or a similar place - Tell us the full name and address of the place where you were staying, address line 2	Text
Current place name/address (line 2)	Text	Enter the next line of the address for the place where you are staying. Fill only if 'In hospital/care home now: Yes' is 'Yes'. Depends on: In hospital/care home now: Yes
Current place postcode	Text	Enter the postcode for the place where you are staying. Fill only if 'In hospital/care home now: Yes' is 'Yes'. Depends on: In hospital/care home now: Yes
Authority/government department paying	Text	Enter the name of the local authority, health authority, education authority, or government department that pays money towards the costs of your stay. Fill only if 'Authority contributes to costs of stay: Yes' is 'Yes'. Depends on: Authority contributes to costs of stay: Yes
Constant Attendance Allowance: War Pension	Checkbox	Check this box if you are getting, or are waiting to hear about, War Pension Constant Attendance Allowance.
Constant Attendance Allowance: Industrial Injuries Disablement Benefit	Checkbox	Check this box if you are getting, or are waiting to hear about, Industrial Injuries Disablement Benefit Constant Attendance Allowance.
Came out of hospital/care home in past 6 weeks: No	Checkbox	Check this box if you have not come out of hospital, a care home, or a similar place in the past six weeks.
Came out of hospital/care home in past 6 weeks: Yes	Checkbox	Check this box if you have come out of hospital, a care home, or a similar place in the past six weeks.
Date went into hospital/care home (recent stay)	Date	Enter the date you went into the hospital, care home, or similar place within the past six weeks. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Date came out of hospital/care home (recent stay)	Date	Enter the date you came out of the hospital, care home, or similar place. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Recent place name/address (line 1)	Text	Enter the full name of the hospital/care home (or similar place) and the first line of its address where you were staying. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Recent place name/address (line 2)	Text	Enter the next line of the address for the place where you were staying. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Recent place name/address (line 3)	Text	Enter the next line of the address for the place where you were staying. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Recent place postcode	Text	Enter the postcode for the place where you were staying. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Reason for going into hospital (recent stay)	Text	Describe why you went into hospital, if you have been in hospital. Fill only if 'Came out of hospital/care home in past 6 weeks: Yes' is 'Yes'. Depends on: Came out of hospital/care home in past 6 weeks: Yes
Account Holder Name	Text	Enter the name of the account holder exactly as shown on the cheque book or bank statement.
Bank or Building Society Name	Text	Enter the name of the bank or building society where the account is held.
Sort Code (First Part)	Text	Enter the first two digits of the 6-digit sort code. Max length: 2 characters
Sort Code (Middle Part)	Text	Enter the middle two digits of the 6-digit sort code. Max length: 2 characters
Sort Code (Last Part)	Text	Enter the last two digits of the 6-digit sort code. Max length: 2 characters
Account Number	Text	Enter your bank account number, filling digits from the left if it is fewer than 10 digits.
Building Society Roll or Reference Number	Text	Enter the building society roll number or reference number for this account, if you have one. Fill only if 'Bank or Building Society Name' is a building society (not a bank). Depends on: Bank or Building Society Name
Pay other benefits into the account above	Checkbox	Check this box if you want any other benefits and entitlements you receive to be paid into the bank/building society account details provided on this page.
Contact Frequency	Text	Enter how often you see the person this form is about (for example, daily, weekly, or monthly).
Illnesses/Disabilities and Effects	Text	Describe the person’s illnesses and/or disabilities and explain how these conditions affect them.
Your Relationship/Role	Text	State your job, profession, or your relationship to the person this form is about.
Your Full Name	Text	Enter your full name.
Daytime Phone Number	Text	Enter your daytime phone number where you can be contacted or a message can be left.
Address Line 1	Text	Enter the first line of your address (for example, building number and street).
Address Line 2	Text	Enter the second line of your address (for example, apartment, suite, or area).
Address Line 3	Text	Enter the third line of your address (for example, town/city or county, if needed).
Postcode	Text	Enter your postcode.
Date	Date	Enter the date you completed this statement.
Consent at question 20 completed	Checkbox	Check this box if you have ticked the relevant consent box and signed the consent at question 20.
Declaration at question 64 signed	Checkbox	Check this box if you have signed the declaration at question 64.
GP details at question 19 included	Checkbox	Check this box if you have included full details of your GP at question 19.
Other health professional details at question 17 included	Checkbox	Check this box if you have included full details for anyone else you have seen at question 17.
Helper details at question 18 included	Checkbox	Check this box if you have included full details for anyone else who helps you at question 18.
Care needs start date at question 28 completed	Checkbox	Check this box if you have completed the care needs start date at question 28. Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Documents Enclosed With Claim	Text	List all documents you are sending with this claim form (for example, reports, certificates, prescriptions, passport copies, or care plans).
Help with your care needs
Help with your care needs - Please tell us anything else you think we should know about the difficulty you have or the help you need	Text
Name details
All other names (in full)	Text	Enter all other names you are known by in full (for example, middle names or previous names).
Nationality	Text	Enter your nationality.
National Insurance (NI) number
National Insurance (NI) number	Text	Enter your National Insurance (NI) number.
No	Checkbox	Check this box if you are a Swiss or EEA national and you were not living in the United Kingdom (UK) before 1 January 2021. Fill only if 'Nationality' is Swiss or an EEA national. Depends on: Nationality
Nationality and EEA/Swiss UK residence before 1 Jan 2021
Full address	Text	Enter the full address where you permanently live.
First name	Text	Enter your first (given) name.
Page 2
No	Checkbox	Check this box if you are not claiming under the special rules.
Yes	Checkbox	Check this box if you are claiming under the special rules (end of life and not expected to live longer than 12 months).
Page 30
Declaration Date	Date	Enter the date you are signing the declaration.
Printed Name	Text	Print your full name as the person making the declaration.
Permanent address
Female	Checkbox	Check this box if your sex is female.
Mobile phone number	Text	Enter your mobile phone number, if you have one.
Second Activity and Help Details (at home)
Second activity (at home)	Text	Enter the second hobby, interest, or social/religious activity you do or would like to do at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Help needed for second activity (at home)	Text	Describe the help you need or would need from another person to do the second activity at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
How often you do the second activity (at home)	Text	State how often you do or would do the second activity at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Second Aid/Adaptation Entry
Second aid or adaptation	Text	Enter the name of the second aid or adaptation you use (for example, magnifier or stairlift). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Prescribed by health care professional (second entry)	Checkbox	Check this box if the aid or adaptation you list on the second line was prescribed by a health care professional (for example, an occupational therapist). Fill only if 'Second aid or adaptation' is filled. Depends on: Second aid or adaptation
How the second aid/adaptation helps	Text	Describe how this second aid or adaptation helps you in daily life. Fill only if 'Second aid or adaptation' is filled. Depends on: Second aid or adaptation
Difficulty using the second aid/adaptation	Text	Describe any difficulty you have using this second aid or adaptation, including whether you need help from another person. Fill only if 'Second aid or adaptation' is filled. Depends on: Second aid or adaptation
Second Illness or Disability Details
Second illness or disability name	Text	Enter the name of your second illness or disability.
How long you have had this condition (second)	Text	Describe how long you have had this second illness or disability.
Medicines or treatments prescribed (second)	Text	List the medicines and/or treatments you have been prescribed for this second illness or disability (or write none).
Dosage and frequency (second)	Text	Enter the dosage and how often you take each medicine or receive the treatment for this second illness or disability (or write none).
Second Outings Activity Details
Second Activity	Text	Enter the second activity you do or would like to do when you go out. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Help Needed for Second Activity	Text	Describe the help you need or would need from another person to do the second activity. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Frequency and Duration of Second Activity	Text	State how often you do or would do the second activity and for how long each time. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Second Test Details
Second test date and type	Text	Enter the date the second test took place and the type of test you had (for example, a treadmill test). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Second test results	Text	Enter the results or outcome of the second test. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Second Waiting List Surgery Details
Date Added to Waiting List	Date	Enter the date you were put on the waiting list for the surgery. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Planned Surgery Type	Text	Describe the surgery you are going to have (for example, hip replacement). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Planned Surgery Date	Date	Enter the date the surgery is planned for, if you know it. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Sex
Date of birth	Date	Enter the person's date of birth.
Do not know	Checkbox	Check this box if you do not know whether you were living in the UK before 1 January 2021. Fill only if 'Nationality' is Swiss or an EEA national. Depends on: Nationality
Sixth Aid/Adaptation Entry
Sixth aid or adaptation	Text	Enter the name of the sixth aid or adaptation you use (for example, magnifier or stairlift). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Prescribed (sixth aid/adaptation)	Checkbox	Check this box if the sixth aid or adaptation you list was prescribed by a health care professional (for example, an occupational therapist). Fill only if 'Sixth aid or adaptation' is filled. Depends on: Sixth aid or adaptation
How this sixth aid/adaptation helps	Text	Describe how this sixth aid or adaptation helps you in your daily life. Fill only if 'Sixth aid or adaptation' is filled. Depends on: Sixth aid or adaptation
Difficulty using this sixth aid/adaptation	Text	Describe any difficulty you have using this sixth aid or adaptation, including if you need help from another person. Fill only if 'Sixth aid or adaptation' is filled. Depends on: Sixth aid or adaptation
Sixth Illness or Disability Details
Sixth illness or disability name	Text	Enter the name of the sixth illness or disability you have.
Sixth illness or disability duration	Text	State how long you have had the sixth illness or disability.
Sixth illness or disability medicines/treatments	Text	List any medicines, treatments, or both that you have been prescribed for the sixth illness or disability (or write none).
Sixth illness or disability dosage and frequency	Text	Describe the dosage and how often you take each medicine or receive each treatment for the sixth illness or disability (or write none).
Third Activity and Help Details (at home)
Activity or hobby (at home) - third entry	Text	Enter the hobby, interest, social activity, or religious activity you do or would like to do at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Help needed for activity (at home) - third entry	Text	Describe the help you need or would need from another person to take part in this activity at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
How often you do this (at home) - third entry	Text	State how often you do or would do this activity at home. Fill only if 'Yes (help needed to take part in hobbies/activities)' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Third Aid/Adaptation Entry
Third Aid or Adaptation Used	Text	Enter the name of the third aid or adaptation you use (e.g., magnifier, stairlift). Fill only if 'Are you claiming under the special rules?' is 'No'. Depends on: No
Prescribed by a health care professional (third aid/adaptation)	Checkbox	Check this box if the third aid or adaptation you list was prescribed by a health care professional (for example, an occupational therapist). Fill only if 'Third Aid or Adaptation Used' is filled. Depends on: Third Aid or Adaptation Used
How the Third Aid/Adaptation Helps	Text	Describe how this third aid or adaptation helps you in daily life. Fill only if 'Third Aid or Adaptation Used' is filled. Depends on: Third Aid or Adaptation Used
Difficulties Using the Third Aid/Adaptation	Text	Describe any difficulty you have using this third aid or adaptation, including if you need help from another person. Fill only if 'Third Aid or Adaptation Used' is filled. Depends on: Third Aid or Adaptation Used
Third Illness or Disability Details
Third illness or disability name	Text	Enter the name of the third illness or disability you have.
How long you have had the third illness or disability	Text	State how long you have had this third illness or disability (for example, two years or about 10 years).
Medicines or treatments for the third illness or disability	Text	List the medicines and/or treatments you have been prescribed for this third illness or disability (or write none).
Dosage and frequency for the third illness or disability	Text	Describe the dosage and how often you take each medicine or receive treatment for this third illness or disability (or write none).
Third Outings Activity Details
Third outing activity	Text	Describe the third activity you do or would like to do when you go out (for example, swimming). Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Help needed for third outing	Text	Describe what help you need or would need from another person to do this third activity. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)
Third outing frequency and duration	Text	State how often you do or would do this third activity and, if applicable, how long you do it each time. Fill only if 'Do you usually need help from another person to actively take part in hobbies, interests, social or religious activities?' is 'Yes'. Depends on: Yes (help needed to take part in hobbies/activities)

Form AA1, Claim for Attendance Allowance Instructions