Personal Independence Payment (PIP) Supporting Evidence

Complete this form only if you have been advised by your GP. Providing detailed information will help with your application.

When answering the following questions please consider your ability to perform each activity:

safely;
to an acceptable standard;
repeatedly (as necessary); and
within a reasonable time.

Please indicate where you are unable to perform these activities without either physical help, or someone prompting you to carry out the activities.

Last Updated: 14/02/2022

Your Details

Full Name

Date of Birth

Mobile Number

Email Address
Your Information

To what extent do my condition(s) affect my ability to prepare food?

To what extent do my condition(s) affect my ability to take appropriate nutrition?

To what extent do my condition(s) affect my ability to manage therapy or monitor my health condition?

To what extent do my condition(s) affect my ability to wash or bathe?

To what extent do my condition(s) affect my ability to manage my toilet needs or incontinence?

To what extent do my condition(s) affect my ability to dress or undress?

To what extent do my condition(s) affect my ability to communicate verbally?

To what extent do my condition(s) affect my ability to read and understand signs symbols and words?

To what extent do my condition(s) affect my ability to engage with other people (who I both know and do not know) face to face?

To what extent do my condition(s) affect my ability to make budgeting decisions?

To what extent do my condition(s) affect my ability to plan and follow journeys (both those that are familiar and unfamiliar to me)?

To what extent do my condition(s) affect my ability to physically move around?
Consent

This form collects your name, date of birth, email, other personal information & medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you & also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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I consent to the practice collecting and storing my data from this form.

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I consent to the practice sending me emails concerning my direct medical care & practice information

I consent for a GP to use this information to compile a report

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Personal Independence Payment (PIP) Supporting Evidence

Your Details

Your Information

Consent