YOU HAVE A PROGRESSIVE DEGENERATIVE NEUROLOGICAL DISEASE.
YOU ARE ENTITLED TO WHAT IS AFTER ALL, A PITTANCE.
BUT ITS A PITTANCE THAT WE NEED.
MAKE SURE YOU CLAIM.
IT WILL BE BACK DATED FROM THE DATE YOUR FORM IS RECIEVED.
IT WILL TAKE BETWEEN 8-13 WEEKS, SO BE PATIENT.
IT IS NOT MEANS TESTED, SO IF YOU ARE LUCKY ENOUGH TO HAVE A MILL OR TWO STASHED, YOU CAN STILL CLAIM.
HERE IS A COPY OF MY SUCCESSFUL CLAIM.
I GOT THE HIGHER MOBILITY AND MIDDLE OF CARE.
Disability Living Allowance
Adult
Are you already in receipt of Disability Living NO
Allowance?
We have recorded the following date as the date 29-8-2007
from which you wish to make this claim for
Disability Living Allowance
Are you claiming under the Special Rules? No
Have you read the notes around Special Rules? Yes
If you live in Wales, would you like to receive future
communications in Welsh?
Submitting for Someone Else
Are you submitting this e-claim for someone else? No
About You
Title Mr
Surname or family name PARKY
All other names in full none
All other surnames or family names you have been PARKY 2
known by or are using now
Sex Male
Address WONDERLAND HOUSE
DEEP SPACE NINE
MIDDLE EARTH
Please confirm these address details are correct Confirmed Correct
Daytime phone number where we can contact you 0123456789
or leave a message
Phone number type Home
Previous address
Postcode
Please confirm these address details are correct
Date of Birth 01/02/1900
National Insurance number AB 12 34 56 YZ
Disability Living Allowance -Adult -DLA1 -
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none PARKY Submitted Date: 01/02/1900
Claim Number: 1234567890ABCD
Nationality BRITISH
Residency UK
Do you normally live in Great Britain? YES
Have you been abroad for 4 weeks or more in the
last 12 months? NO
Illnesses and Disablities
Illnesses and disabilities
What are your illnesses or disablities? PARKINSONS & DIABETES
Tablets, medicines and other treatments LIST EVERYTHING
What medicines, tablets or other treatments have
been prescribed for your illnesses or disabilities? LIST EVERYTHING
Have you had a medical examination in the last 6
months, in connection with any social security
benefit? NO
Please tell us which benefit? N/A
Renal Dialysis NO
Are you on Kidney Dialysis NO
More About You
You are blind or partially sighted MEDS MAKE MY EYES BLURRED
You are both deaf and blind NO
You have problems with hearing even with a
hearing aid MY HEARING IS GETTING WORSE
You have problems with speech, which mean that
you cannot communicate well with other people MY SPEECH IS NOW SLURRING QUITE BADLY AND THE VOLUME IS DIMINISHING
British
Yes
No
I SUFFER FROM PARKINSONS DISEASE AND
ALSO DIABETES.
I WAS DIAGNOSED WITH PD ABOUT 5 YEARS
AGO BUT HAVE PROBABLY HAD IT FOR 10
YEARS.
THE DIABETES DEVELOPED JUST OVER A
YEAR AGO AND IS THE TYPE 2 FORM.
MADOPAR I X DAY
ROTIGOTINE NEUPRO PATCH 1 X DAY
ROPINIROLE 1 X 3 PER DAY
SINEMET PLUS 1.5 X 3 PER DAY
SINEMET CR 1 X 3 DAY
PROPRANOLOL 2 X 3 PER DAY
METFORMIN 1 X 3 PER DAY
GLICLAZIDE 1 X DAY
ASPIRIN 1 X DAY
No
No
Yes
Disability Living Allowance -Adult -DLA1 -CUSTOMER COPY ONLY DO NOT POST Page 2 of 19
ALL THE ANSWERS TO ALL THE FOLLOWING QUESTIONS ARE BELOW, SO IT WOULD BE WISE TO PRINT THESE SHEETS OFF
You have a learning difficulty
You have a severe learning disability and severe
behavioural problems
You have a mental health problem
You have had both legs amputated above the
ankle or through the ankle, or you were born
without legs or feet
You cannot walk at all
You have some other problem not on this list
Have you been assessed for things such as home
help, meals on wheels or disability aids, or do you
have a care plan or an occuaptional therapy report
Your Condition
Walking Outdoors
Do you have physical problems walking?
If you have an amputation, please tell us the level
of the amputation
Tell us about anything you use to help you walk.
If the effort of walking would be dangerous for you,
tell us about this.
Tell us roughly how far you can walk before you
feel severe discomfort
Tell us how long on average it takes you to walk
this far
How many days a week do you have this amount
of difficulty walking?
Help Outdoors
Do you need someone with you when you are
outdoors?
Describe in your own words the problem you have
and the help you need when you are outdoors
How many days a week do you need someone
with you when you are outdoors?
Falls or Stumbles
Yes
Yes
Yes
No
Yes
NONE
A WALKING STICK
I GET VERY TIRED QUICKLY AND MY BALANCE
IS VERY POOR. I FALL OVER NOW AND THEN
IF I GET A DIZZY SPELL THROUGH TAKING MY
MEDICATION
EVERY 50 TO 100 YARDS
UP TO 5 MINUTES
7
Yes
EVERY TIME I GO OUT, WHICH IS GETTING
LESS OFTEN NOW, I NEED SOMEONE TO ACCOMPANY
ME TO DRIVE ME OR BE THERE IN
CASE I HAVE A DIZZY SPELL OR STUMBLE
7
Disability Living Allowance -Adult -DLA1 -CUSTOMER COPY ONLY DO NOT POST Page 3 of 19
Do you sometimes fall or stumble, even in places
you know well because of your disability or the
effect of your medication?
Why do you fall or stumble?
Tell us where you might fall or stumble
Describe in your own words the problems you have
and the help you need when you fall or stumble
Tell us roughly how often you fall or stumble
Moving about indoors
Do you have problems moving about indoors?
Does someone have to tell you or encourage you
to move about indoors?
Describe in your own words the problems you have
and the help you need moving about indoors
Tell us about any ways your home has been
adapted or about any equipment you use to help
move about indoors. Tell us if someone helps you
to use the equipment.
How long on average do you need help moving
about each time?
Yes
MY BALANCE HAS REALLY DETERIOTED
OVER THIS LAST 9 MONTHS AND I STUMBLE
QUITE REGULARLY OR BUMP INTO THINGS.
MY SHINS ARE COVERED IN CUTS AND
BRUISES. THE MEDICATIONS ARE THE CAUSE
OF THE DIZZY SPELLS AND OCCASSIONAL
SLEEP ATTACKS.
ANYTIME BUT MAINLY WITHIN AN HOUR OF
TAKING MY MEDICATIONS.OR IF I AM GOING
UPSTAIRS WHICH I TRY TO KEEP TO A MINIMUM
NOW. I HAVE FALLEN OFFCHAIRS BECAUSE
I TURNED TOO QUICKLY.
WHEN I STUMBLE OR FALL, I WOULD NEED
SOMEONE TO ASSIST ME TO GET UP. ITS GOT
WORSE RECENTLY BECAUSE I DONT HAVE
THE STRENGTH ANY MORE TO PULL MYSELF
UP. I TRY TO GET TO MY KNEES AND THEN
ASK FOR HELP.
I FALL AT LEAST ONCE A DAY, UNLESS I STAY
IN BED,AND I STUMBLE AND SHUFFLE ON A
REGULAR BASIS.ITS HARD TO PUT A FIGURE
ON IT, BUT ABOUT 5 TO 10 TIMES A DAY.
Yes
Yes
I HAVE PRACTICALLY STOPPED GOING UPSTAIRS
NOW EXCEPT TO CHANGE CLOTHES. I
HAVE FOR THE LAST 3/6 MONTHS BEEN
SLEEPING ON THE SOFA. THE STAIRS ARE
THE MAIN PROBLEM ESPECIALLY COMING
DOWN. I AM ALWAYS AFRAID I MIGHT FALL
DOWN THEM. I TEND TO STAY IN THE LIVING
ROOM WITH AN OCCASSIONAL TRIP TO THE
TOILET OR KITCHEN
WE HAVEN,T THE MONEY TO ADAPT ANYTHING,
BUT I,AM LOOKING TO CHANGE THE
DINNING ROOM INTO A BEDROOM. I WOULD
ALSO LIKE TO GET EXTRA RAILS PUT UP
ABOUT THE HOUSE , ESPECIALLY THE BATHROOM,
WHICH I DOON,T USE VERY OFTEN
BECAUSE ITS UPSTAIRS PLUS I FIND IT HARD
TO WASH (DYSKENSIAS KICKS IN AND RESTRICTS
MY MOVEMENTS)
AT LEAST A MINUTE TO GET UP, AND 5 MINS
TO GO UPSTAIRS
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How many days a week do you need help moving
about indoors?
How many times a day do you need help?
Help Needed
Waking, getting up and going to bed
Do you have problems getting out of bed in the
morning or into bed at night?
Does someone have to tell you or encourage you
to get out of bed in the morning or into bed at
night?
Describe in your own words the problems you have
and the help you need getting out of bed in the
morning or into bed at night
Tell us about any equipment you use to help you
get out of bed in the morning or into bed at night.
Tell us how the equipment helps you and how
useful it is. Tell us if someone helps you to use the
equipment.
How many days a week do you need help to get
out of bed in the morning or into bed at night?
How long on average do you need help for each
time?
When in bed
Do you have problems when you are in bed?
Describe in your words the problems you have and
the help you need when you are in bed?
7
DEPENDS IF PEOPLE ARE HOME, IF THEY
ARE,PROBABLY 6
Yes
Yes
I TEND NOT TO USE THE BED ANYMORE AND
SLEEP ON THE SOFA IN THE DOWNSTAIRS
LIVING ROOM.MAINLY DUE TO THE STAIRS
BUT ALSO BECAUSE I SUFFER BADLY WITH
INSOMNIA.MY WIFE TRIES HARD TO GET ME
TO GO TO BED BUT IT SUITS ME BETTER
DOWN STAIRS
BY SLEEPING ON THE SOFA ITS EASIER TO
GET ON AND OFF BECAUSE ITS LOWER. I
ROLL OFF AND THEN PULL MYSELF UP BY
THE SOFAS EDGE. IF I WAS IN BED IT WOULD
BE MORE DIFFICULT AND WOULD ALSO DISTURB
MY WIFES SLEEP WHICH I TRY MY BEST
NOT TO DO.IF I DID RETURN TO SLEEP UPSTAIRS
I WOULD REQUIRE RAILS TO ASSIST
ME TO GET UP.
3
5 MINS
Yes
I HAVE RESTLESS LEG SYNDROME WHICH
HAS GOT WORSE OVER THE LAST 6
MONTHS.THIS IS ONE OF THE REASONS I
NOW SLEEP ON THE SOFA.WHEN IN BED AND
I WANT TO GET UP , I WOULD REQUIRE A
SHOVE TO ROLL OVER OR EXIT THE BED. BECAUSE
OF THE RESTLESS LEGS COUPLED
WITH INSOMNIA I WAS CONSTANTLY ASKING
MY WIFE TO GIVE ME A PUSH WHICH IS UNFAIR
ON HER. BY USING THE SOFA, I CAN USE
THE BACK PART FOR LEVERAGE TO ROLL OR
EXIT
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Tell us about any equipment you use to help you
when you are in bed. Tell us how the equipment
helps you and how useful it is. Tell us if someone
helps you use the equipment.
How long on average do you need help for each
time?
How many nights a week do you need help when
you are in bed?
How many times a night do you need help?
Toilet Needs
Do you have problems coping with your toilet
needs?
Does someone have to tell you, remind you or
encourage you to deal with your toilet needs?
Describe in your own words the problems you have
and the help you need with your toilet needs during
the day
How long on average do you need help each time
during the day?
How many days a week do you need help with
your toilet needs?
How many times a day do you need help with your
toilet needs?
Describe in your own words the problems you have
and the help you need with your toilet needs during
the night
How long on average do you need help each time
during the night?
How many nights a week do you need help with
your toilet needs?
How many times a night do you need help with
your toilet needs?
Please tell us where the toilet is in the house, and
about any special equipment you use to help you
with your toilet needs.
I HAVE NO EQUIPMENT, BUT I GET SILLY
IDEAS NOW AND THEN FOR SOMEONE TO
MAYBE INSTALL SOME SORT OF PULLEY SYSTEM
IF IN BED, 1 MINUTE EACH TIME
7
IF IN BED AND NOT THE SOFA, 5 TO 10 TIMES
Yes
Yes
i find it very difficult to open and close my zipper. i
tend to sit on the toilet now just to urinate. mainly
to stop the dribbling and making a mess. that
brings it own prolems. because of the rigidity in my
body, my hands wont do what my brain is telling it
to do most of the time, which stops me from pulling
up my trousers. it takes ages sometimes. i now
wear elasticated shorts around the house to make
things easier. my wife has to help now and then to
pull them up. i am lucky to have a downstairs toilet.
5 minutes
7
twice a day, maybe three
due to me sleeping downstairs and having insomnia
i rarely require assistance at night.i have a bedpan
but i dislike using it. occassionally IF my wife
has had to help out
5-10 mins
7
once, maybe twice
i am lucky to have 3 toilets in the house. two upstairs
and one downstairs. i have no special equipment
but i do use the hand basin or the radiator to
get up.
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Washing and Bathing
Do you have problems washing, having a bath or
shower, or looking after your appearance?
Does someone have to tell you, remind you or
encourage you to wash or take a bath or shower?
Describe in your own words the problems you have
and the help you need washing, bathing or
showering, or looking after your appearance. If you
need to wash or bath or shower more than once a
day, please tell us why. If you have bed baths, tell
us how long
Tell us about any equipment you use to help you
with washing, bathing or showering, or looking
after your appearance. Tell us how the equipment
helps you and how useful it is. Tell us if someone
helps you use the equipment.
How long on average does it take you to wash or
to have a bath or shower?
How many days a week do you need help with
washing, bathing or showering, or looking after
your appearance?
How many times a day do you need help with
washing, bathing or showering, or looking after
your appearance?
Dressing and Undressing
Do you have problems getting dressed or
undressed?
Does someone have to tell you, remind you or
encourage you to get dressed or undressed?
Describe in your own words the problems you have
and the help you need getting dressed or
undressed.
Tell us about any equipment you use to help you
get dressed or undressed. Tell us how the
equipment helps you and how useful it is. Tell us if
someone helps you use the equipment.
How long on average does it take you to get
dressed or undressed each time?
How many days a week do you need help getting
Yes
Yes
my personnal hygiene has really deterioted over
this past year. because its so difficult to bathe or
shower i dont do it as often as i should. sometimes
i go a week without a bath and just have a flannel
wash instead. my right hand is still quite functional
and that does all the work. i only shave on a good
day, which is not very often. because of the trmors
it is very precarious shaving, and i refuse to let my
wife do such a personnal thing.
I HAVE NO SPECIAL EQUIPMENT ALTHOUGH I
WOULD LIKE TO INSTALL A BIGGER BATH
WITH PLENTY OF RAILS
ONE AND A HALF HOURS
7
ONCE , MAYBE TWICE
Yes
Yes
I CANNOT GET DRESSED ALONE. I NEED ASSISTANCE
TO TIE LACES, KNOT TIES, BUTTON
SHIRTS ,BUCKLE BELTS AND PUT IN CUFFLINKS.
TUCKING IN SHIRTS AND PULLING UP
TROUSERS IS ALSO NEEDING HELP.
BECAUSE MY FEET ARE NEARLY ALWAYS
SWOLLEN, I SOMETIMES APPLY VASELINE
ONTO MY FEET SO MY SOCKS SLIDE ON EASIER.
SHOE HORNS ARE A MUST WHEN PUTTING
ON SHOES.
45 MINUTES
7
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dressed or undressed?
How many times a day do you need this help?
Cooking a meal
Would you have problems because of your illness
or disability if you prepared a cooked main meal for
yourself?
Describe in your own words the problems you
would have and the help you would need if you
prepared a cooked main meal for yourself.
How many days a week would you have these
problems?
Eating and Drinking
Do you have problems at mealtimes?
Does someone have to tell you, remind you or
encourage you to feed yourself or have a drink?
Describe in your own words the problems you have
and the help you need at mealtimes.
Tell us about any equipment you use to help you at
mealtimes. Tell us how the equipment helps you
and how useful it is. Tell us if someone helps you
use the equipment.
How long on average do you need help for each
time?
How many days a week do you need help at
mealtimes?
How many times a day do you need help at
mealtimes?
Medication
Do you have problems coping with medical
treatment?
Does someone have to tell you, remind you or
encourage you to take your medication?
TWICE
Yes
I CAN ONLY PREPARE PACKET, TV STYLE DINNERS.
CUTTING AND PEELING VEG ANDMEAT
AND DEALING WITH HOT PANS WOULD BE
VERY DANGEROUS FOR ME. BECAUSE OF
THE INVOLUNTARY SPASMS AND TREMORS I
COOK ONLY COOK THE BASIC OF MEALS
7
Yes
Yes
I HAVE TROUBLE PUTTING A KNIFE INTO MY
MOUTH BECAUSE OF SPASMS AND
TREMORS. A SPOON IS MORE USER
FRIENDLY. ANY MEAT HAS TO BE CUT UP FOR
ME UNLESS I EAT WITH MY FINGERS
(USUALLY CHICKEN). I TEND TO EAT CONVINIENT
FOODS A LOT MORE NOW, BUT THEY
ARE EXPENSIVE AND NOT GOOD FOR MY DIABETES
NO SPECIAL EQUIPMENT ,JUST A BRILLIANT
WIFE
10 MINS
7
2
Yes
Yes
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Describe in your own words the problems you have
and the help you need with medical treatment. And
tell us what would happen if you did not take your
medication during the day
How long on average do you need help each time
during the day?
How many days a week do you need help with
your medical treatment?
How many times a day do you need help with your
medical treatment?
Describe in your own words the problems you have
and the help you need with medical treatment. And
tell us what would happen if you did not take your
medication during the night.
How long on average do you need help each time
during the night?
How many nights a week do you need help with
your medical treatment?
How many times a night do you need help with
your medical treatment?
Someone to keep an eye on you
Do you need someone to keep an eye on you?
Describe in your own words why you need
someone with you during the day.
How long on average do you need someone with
you each time during the day?
How many days a week do you need someone
with you?
How many times a day do you need someone with
you?
Describe in your own words why you need
someone to be awake to watch over you.
How long on average do you need someone to be
MY PILLS COME IN JACKETS THAT ARE VERY
FIDDLY. MY WIFE PUTS THEM IN LITTLE CONTAINERS
FOR EACH SET OF DOSAGES.
WITHOUT MY MEDS MY SYMPTOMS WOULD
WORSEN AND I WOULD BE TOTALLY INCAPSITATED.
THE TRANSDERMAL PATCHES CANNOT
BE PLACED ON THE SAME PART OF THE
BODY WITHIN A 14 DAY PERIOD. I WOULD
GET CONFUSED WITHOUT ASSISTANCE.
5-10 MINS
7
3
MY LAST MEDS ARE TAKEN LAST THING AT
NIGHT. I DO NOT TAKE ANY DURING THE
NIGHT. BUT MY WIFE CHECKS TO SEE IF THE
NEUPRO PATCH IS STILL STUCK TO MY BODY.
THEY DO TEND TO PEEL OFF QUITE EASY.
5 MINS
7
1
Yes
IN FAMILIAR SURROUNDINGS LIKE MY HOME
THE NEED FOR A OBSERVER/LOOKING OUT
FOR ME IS LESSENED BUT OUT DOORS I
WOULD BE QUITE FRIGHTENED ON MY OWN
IN CASE I FELL OR STUMBLED
I HOUR
7
ONCE OR TWICE
I RARELY SLEEP NOW WITH CAT NAPS TAKEN
INSTEAD. THROUGH THE NIGHT I TEND TO
WATCH A LOT OF TV AND RARELY LEAVE THE
SOFA. MY WIFE LEAVES MOST THINGS I
WOULD NEED ON THE TABLE NEARBY.
5 MINS
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awake during the night to watch over you?
How many nights a week do you need someone to
be awake to watch over you?
How many times a night do you need someone to
be awake to watch over you?
Blackouts, fits or seizures
Do you have dizzy spells, blackouts, fits, siezures
or something like this?
Describe in your own words the problems you have
and the help you need with dizzy spells, blackouts,
fits, seizures or something like this during the day.
How long on average do you need help each time
during the day?
Tell us roughly how often you have a dizzy spell,
blackout, fit or seizure during the day.
Describe in your own words the problems you have
and the help you need with dizzy spells, blackouts,
fits, seizures or something like this during the night.
How long on average do you need help each time
during the night?
Tell us roughly how often you have a dizzy spell,
blackout, fit or seizure during the night.
Mental Health
Do you have problems because of your mental
health?
Describe in your own words the things you do or
cannot do, or the experiences you have had,
because of your mental health.
Tell us roughly how often this happens, and how
long you need help for when it happens.
7
1
Yes
I GET DIZZY SPELLS ALMOST EVERY DAY,
CAUSED BY THE MEDS. I ALSO HAVE SLEEP
ATTACKS THAT LAST ABOUT 10 SECONDS .
NOT EXACTLY A BLACKOUT , MORE OF A
NODDING OFF. A FEW TIMES I HAVE COLLAPSED(
DIABETES
5 -10 MINS REASSURANCE MAINLY
I GET DIZZY SPELLS NEARLY EVERY TIME I
TAKE MY MED
I RARELY HAVE TROUBLE WITH DIZZY SPELLS
THROUGH THE NIGHT BECAUSE I DONTTAKE
ANY MEDS EXCEPT THE PATCH. I DO LITTLE
MOVING ABOUT , SO ITS ONLY IF IVE FORGOTTEN
TO TAKE MY MEDS AT THE ALLOTED
TIME.
10 MINS
TWICE A MONTH
Yes
I DO GET DEPRESSED AND SO FAR I HAVE
REFUSED MEDS FROM THE SPECIALIST
NURSE. MY DEPRESSION STEMS FROM THE
FACT I CAN NO LONGER DO MY JOB, PLAY
GOLF , GO DOWN THE PUB, JUST LEADING A
NORMAL LIFE AGAIN
IT VARIES , BUT I,LL HAVE THE BLUES FOR A
COUPLE OF DAYS THEN SNAP OUT OF IT. IT
ALWAYS RETURNS THOUGH. I HAVE JUST
BEEN REFERRED TO A PSYCHIATRIST BY MY
GP AND I,AM WAITING FOR MY FIRST APPOINTMENT
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Communicating with other people
Do you have problems communicating with other
people?
Describe in your own words the problems you have
and the help you need communicating with other
people.
Tell us about any equipment you use to help
communicate with other people. Tell us how the
equipment helps you and how useful it is. Tell us if
someone helps you use the equipment.
How long on average do you need help each time?
How many days a week do you need someone to
help communicate with other people?
How many times a day do you need someone to
help you communicate with other people?
Help you need when you go out
Yes
I USED TO BE A CONFIDENT PERSON AT
HOME AND ESPECIALLY AT MY WORK AS A
CONSTRUCTION MANAGER. PARKINSONS
PUT PAID TO THAT. MY TREMORS GAVE CLIENTS
ANND COLLEGUES THE IMPRESSION OF
A HEAVY DRINKER. I STARTED SITTING ON MY
LEFT HAND TO COVER UP THE SHAKING. MY
SPEECH STARTED SLURRING AND MY TYPING
GOT WORSE DAILY. BODY LANGUAGE IS AN
IMPORTANT INGREDIENT IN COMMUNICATING
WITH PEOPLE, BUT MINE DID LITTLE TO ASSIST
ME. OVER THE LAST FEW YEARS I
LOST COMMAND AND RESPECT FROM MY
WORKERS.
I,VE TRIED VOICE RECOGNITION SOFTWARE
BUT I,AM NOT OVERLY IMPRESSED CONSIDERING
THE COST.MY BOSSES GAVE ME AN
ASSISTANT TO BACK ME UP IF MY SLURRING
GOT TOO BAD
1 HOUR USUALLY SOMETIMES 2 HRS IF I HAD
PLENTY ON.
5
ONCE OR TWICE AT WORK BUT NOT AT HOME
You have recorded 1 instance(s) of what you would do if you had the help you need when you go out during
the day or evening.
Additional day/evening Help 1
What you do or would do if you had the help you SOME SORT OF EXERCISE REGIME WOULD
need when you go out during the day or evening BENEFIT ME. I WOULD LIKE A ROUND OF
GOLF ALBEIT TO BE DRIVEN IN A BUGGY.
AND GOING TO SEE A FOOTBALL MATCH
AGAIN.
How many days a week? 3
How many times in a day? 1
How long do you usually need help for each time? 4 HOURS
What help do you need from another person? CONFIDENCE THAT THEY CAN HELP ME IF
NEEDED.
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Help you need at home
You have recorded 1 instance(s) of what you would do if you had the help you need at home.
Additional help at home 1
What you do or would do if you had the help you I WANT TO LEARN MORE COMPUTER SKILLS
need at home SO THAT ONE DAY I MIGHT RETURN TO
WORK IN SOME CAPACITY. TRAINING REQUIRED.
How many days a week? 3
How many times in a day? 1
How long do you usually need help for each time? 2-3 HOURS
What help do you need from another person? TRAINING AND EDUCATION AND COMPANY.
More Information
Describe in your own words any ways that your
illnesses or disabilities affect you that you have not
been able to put anywhere else on this form.
Hospital and Residential Care
Nights in hospital
Are you in hospital now?
Nights in Residential Care
Are you in residential care now?
The Past 6 weeks
Have you come out of hospital or residential care
in the past 6 weeks?
CONCERNING WASHING AND BATHING
when my wife can coerse me into the bath , i try to
cover as much as i can myself, but my wife has to
wash my hair, my back and neck and my feet and
lower legs. drying myself is also a problem. i
cant co-ordinate to dry the awkward areas. i can
do most places my right hand can reach and my
wife does the rest. when i have a bath , its normally
last thing at night so that i dont have to get
dressed again.
I also gives my wife no respite. she is more a captive
to this disease than i am. if it affects my wife
badly ,it then in turn hurts me.
most of my friends i rarely see, and i cant blame
them. we have nothing in common except memmories.
i miss my work and collegues and something to get
up for in the mornings.
No
No
No
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When Difficulties Began
If you have problems with getting around, tell us 01/10/2006
when you started to have problems you have told
us about
If you have problems with personal care, tell us 01/10/2006
when you started to have the problems you have
told us about
Who to Contact
Is there someone else who could tell us about your Yes
illness or disability?
Please tell us their name DR WHO
Their Address
THE TARDIS
Postcode 5TH MOON FROM SUN
Please confirm these address details are correct Confirmed Correct
Their Phone Number 01234 456789
What is their job GENERAL PRACTIONER
When did you last see them? 01/01/1901
Doctors and Specialists
Doctor, GP or health centre
Do you have a GP? Yes
Please tell us their name
Their address
Postcode
Please confirm these address details are correct Confirmed Correct
What is their phone number
When did you last see your doctor about your 08/08/2007
illness or disabilities?
Hospital doctors and specialists
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Have you seen any hospital doctor or specialist in Yes
the last 12 months because of your illnesses or
disabilities
You have recorded 1 hospital doctor or specialist
Doctors and Specialists 1
What is their name? NEURODUDE
Hospital address
Postcode CLOUD 9
Please confirm these details are correct Confirmed Correct
Hospital phone number
Hospital record number
When did you last see your hospital doctor or 04/06/2007
specialist?
What illnesses/disabilities do you see them about? DR WHO IS THE CONSULTANT
NEUROLOGIST I SEE ABOUT MY PARKINSONS
DISEASE.
MISS JO IS THE PD NURSE WHO ASSISTS HIM.
Consent
The Department for Work and Pensions or any Iagree
doctor, including your GP, or any doctor providing
medical services on behalf of an organisation
approved by the Secretary of State, may ask any
persons or organisations for any information,
including medical information, which is needed to
deal with: this claim for benefit, or any appeal or
other reconsideration of a decision in relation to
this claim and that the information may be given to
that doctor or to the Department.
Please type your full name GET YOUR GP TO FILL THIS IN
Someone Who Knows You
Title
Surname or family name
All other names in full
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Address
Postcode
Please confirm these details are correct
Daytime phone number
Please give phone number type
Benefits, Pension and Tax Credits
Benefits you are receiving
State Retirement Pension No
Bereavement Benefits No
Incapacity Benefit No
Severe Disablement Allowance No
Attendance Allowance No
Disability Living Allowance No
Constant Attendance Allowance paid with No
Industrial Injuries Disablement Benefit NO
Disability Allowance in the last 3 years NO
Attendance Allowance No
Disability Living Allowance No
About War and Service Pensions
Are you getting or waiting to hear about a War No
Pension?
Tell us about any supplements or allowances you NONE
are getting with your pension, or are waititng to
hear about
Income Support, Jobseeker's Allowance or Pension Credit
Are you getting or waiting to hear about Income No
Support, Jobseeker's Allowance or Pension
Credit?
Is anyone else within your household getting or No
waiting to hear about Income Support, Jobseeker's
Allowance or Pension Credit for you?
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Tax Credits
Is anyone within your household getting or waiting
to hear about Child Tax Credit?
No
Is anyone within your household getting or waiting
to hear about Working Tax Credit?
No
Making payments to you
Do you want to tell us about the account you want No
to use for your Disability Living Allowance?
More information about bank accounts
I intend to open an account
I would like information about how i can be paid by Yes
other means
Declaration
I declare that the information I have given on this e-claim is correct and complete as far as I know and
believe.
I understand that if I knowingly give false information, I may be liable to prosecution or other action.
I understand that I must promptly tell the office that pays my Disability Living Allowance of anything that may
affect my entitlement to or the amount of that benefit.
I understand that the Department may use the information which it has now or may get in the future to decide
whether I am entitled to
-the benefit I am claiming
-any other benefit I have claimed
-any other benefit I may claim in the future.
This is my claim for Disability Living Allowance
Please type your full name PARKY
I certify that the name that I have typed above as Yes, I certify
my signature is a valid method of establishing that
this is my claim for Disability Living Allowance and
that I have read and understood all the statements
on this page.
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What will happen next
This is your reference number. Please make a
note of it in case you need to contact us 1-2345678
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Disability Living Allowance and
other benefits
This note contains two separate pieces of information. The first part is for you and is about your claim for
Disability Living Allowance. The second part is for your carer, if you have one, and gives information about
Carer's Allowance.
Please read this information and bring it to the attention of your carer, if you have one. To print this page,
select "Print this page".
For you -your benefit could be affected if someone claims Carer's Allowance for providing care for
you
If your claim to Disability Living Allowance is successful, you may receive an extra amount called the severe
disability premium (or additional amount for severe disability in Pension Credit) paid as part of
ā¢ Income Support
ā¢ Pension Credit
ā¢ Housing Benefit or Council Tax Benefit
If someone claims Carer's Allowance for providing care to you and he or she is are paid Carer's Allowance
you may not be able to receive this extra amount. For more information about this, contact the office dealing
with these benefits.
For your carer -about Carer's Allowance
If you are caring for someone who is intending to claim Disability Living Allowance, you may wish to make a
claim for Carer's Allowance at the same time. You should not wait until the person you are caring for
receives a decision on their claim for Disability Living Allowance. If you do not make a claim at the same time
you could lose benefit. Ask for the claim pack DS700.
Carer's Allowance and other social security benefits
Payment of some other social security benefits affects payment of Carer's Allowance. This means if you are
receiving another benefit you may not be paid Carer's Allowance or any payment may be reduced. However
even if you cannot be paid, being entitled to Carer's Allowance means that you may be able to get an extra
amount paid with income-based Jobseeker's Allowance, Income Support, Pension Credit, Housing Benefit or
Council Tax Benefit
How to obtain help and advice and claim Carer's Allowance
ā¢ You can obtain information from the Department for Work and Pensions website (
www.dwp.gov.uk)
and claim on-line by selecting 'Disabled People and Carers' and then following the links to the Carer's
Allowance e-service.
ā¢ You can write to Carer's Allowance Unit, Palatine House, Lancaster Road, Preston, PR1 1HB or phone
01253 856123 (text phone 01772 899489 for people with hearing or speech difficulties) or email to
[email protected] ā¢ You can ring the Benefit Enquiry Line (BEL) on 0800 88 22 00. This is a confidential telephone service
for people with disabilities, their representatives and their carers.
ā¢ Your local social security office and many local associations such as Citizens Advice can provide claim
forms and help with completion.
The claim pack and the website contain notes which explain Carer's Allowance in more detail. Claim forms
can also be provided in large print or Braille. Other conditions of entitlement apply. This is not intended to be
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a complete statement of law and you should not rely on it as such.
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