Question 1a
Tell us in the space below:
- what health condition or disability do you have?
- the approximate start date
You don’t need to go into any detail about how your conditions affect you – you can add these details in questions 3 to 15.
You don’t need to be too specific about the date if you’re not sure – the year it started will be enough.
Example
Name of your condition or disability | Approximate start date |
Agoraphobia | 2012 |
Arthritis | 2009 |
Question 1b
Tell us about tablets or other medication you are taking or will be taking and the dosage.
This includes anything you pay for yourself (for example, painkillers) as well as anything you’ve been prescribed.
If you’re not sure whether a tablet or medication is relevant, it’s best to include it anyway.
Write down how often you take each medicine, as well as the strength and dosage if you know it – for example “2 tablets, 50mg, 3 times a day”. You can find the strength on the packet or the patient information leaflet that comes with the medicine.
If you’ve got a printed prescription list you can attach this to your claim form – write your name and National Insurance number on it.
Side effects from medication
If you have medication to help you with side effects from another medication, you should include it.
Also, if there’s medication you should take but can’t because of the side effects you have, include it here too.
Example
Mary takes a pain-relieving tablet for arthritis and this tablet makes her feel sick. Her doctor prescribed her a tablet to stop her feeling sick.
Question 1c
- when your treatment or therapy started or when it’s due to start
- how often your treatment or therapy is
- the dates of any operations you’re going to have
Check how to fill in your claim form
- Q1: listing your conditions, medications and treatments
- Q2: listing your health professionals
- Q3: preparing and cooking a meal
- Q4: eating and drinking
- Q5: managing treatments
- Q6: washing and bathing
- Q7: managing toilet needs
- Q8: dressing and undressing
- Q9: communicating verbally
- Q10: reading
- Q11: mixing with other people
- Q12: making decisions about money
- Q13: going out
- Q14: moving around
- Q15: additional information