Form WCA50
About you
Q1. First name
About you
Q2. Last name
About you
Q3. National Insurance (N I) number
Guidance: Your NI number can be found on the letter we have sent with this form.
About you
Q4. Address
About you
Q5. Mobile phone number, if you have one
More information about you
Q6. Date of birth
More information about you
Q7. Any other contact telephone numbers
More information about you
Q8. Your email address, if you have one
More information about you
Q9. Are you pregnant?
Options: No; Yes
Guidance: When is your baby due? This information will help us find your medical records more quickly. We will not share or use this information for any other purpose.
More information about you
Q10. Have you been in hospital for over 28 days in the last 12 months?
Options: No; Yes
Guidance: What date did you leave? Go to question 12
More information about you
Q11. Please tell us the dates you were in hospital. Give an approximate date if you cannot remember.
Guidance: From To Name and address of the hospital. Postcode
More information about you
Q12. Have you been released from prison in the last 6 months?
Options: No; Yes
For people filling in this questionnaire for someone else
Q13. Are you filling in the form for someone else?
Options: No; Yes
Guidance: Go to ‘About your General Practitioner (GP) or the doctor’s surgery’
For people filling in this questionnaire for someone else
Q14. Your first name
For people filling in this questionnaire for someone else
Q15. Your last name
For people filling in this questionnaire for someone else
Q16. Your address
For people filling in this questionnaire for someone else
Q17. A phone number we can contact you on
For people filling in this questionnaire for someone else
Q18. Why are you filling in the form for them?
Options: I am an appointee appointed by the Department for Work and Pensions (DWP); I am a Deputy; I am a Corporate Acting Body or Corporate Appointee; I am a carer; I am a friend/relative; Other
Guidance: Please tell us your connection to the person the questionnaire is about and why you are filling in this questionnaire for them.
About your General Practitioner (GP) or doctor’s surgery
Q19. Tell us either your GP’s name or the name of the doctor’s surgery you attend, or both if known.
About your General Practitioner (GP) or doctor’s surgery
Q20. Their phone number
About your General Practitioner (GP) or doctor’s surgery
Q21. Their address
About other healthcare professionals, carers, friends or relatives
Q22. Their name
About other healthcare professionals, carers, friends or relatives
Q23. Their job title
About other healthcare professionals, carers, friends or relatives
Q24. Their phone number
About other healthcare professionals, carers, friends or relatives
Q25. Their address
Sharing information about your disability, illness or health condition
Q26. Do you give consent for your doctor or other relevant professionals to give DWP more information about your disability, illness or health condition?
Options: Yes - I have read and understood how DWP uses information and agree information about my health can be shared with DWP or the healthcare professionals that work for DWP.; No - Information about my health cannot be shared with DWP or the healthcare professionals that work for DWP.
Cancer treatment
Q27. Have you been diagnosed with cancer?
Options: No; Yes
Guidance: Go to ‘About your disabilities, illness or health conditions’
Cancer treatment
Q28. Are you having, waiting for or recovering from any of the following treatment for cancer?
Options: • chemotherapy; • biological treatment/immunotherapy; • hormonal treatment; • targeted therapy, or; • radiotherapy.
Guidance: If you are having, waiting for or recovering from any of the cancer treatments listed in question 28, please make sure pages 23 and 24 are filled in and signed by your healthcare professional. This may include a GP (who may charge a fee), hospital doctor or clinical nurse who is aware of your cancer treatment.
Cancer treatment
Q29. Do you have other health problems, as well as cancer and the problems resulting from your cancer treatment?
Options: No; Yes
Guidance: If you have other health problems as well as cancer and the problems resulting from your cancer treatment, please fill in the rest of the form as well as page 23. When your healthcare professional has signed page 24 and you have signed page 21 you can then return this questionnaire using the enclosed envelope.
About your disabilities, illness or health conditions
Q30. What are your disabilities, illness or health conditions?
Guidance: Tell us how they affect you, when they started and if you think any of your conditions are linked to drugs or alcohol. Also tell us about any aids you use, such as a wheelchair or hearing aid and anything else you think we should know about your disabilities, illness or health conditions. Name of your condition, illness or disability and how it affects you Any aids you use for your condition, illness or disability Approximate start date
About your disabilities, illness or health conditions
Q31. What tablets, liquids, inhalers or other medication are you taking and are there any side effects?
Guidance: Tell us about tablets or other medication you are taking and the dosage. If you are sending in a copy of your prescription, please tell us about the side affects. Medication Dosage How often do you take it? Do you have any side effects? Example - Paracetamol 500mg Twice a day Dizziness If you need more space, please use the ‘Other information’ section on page 20 or a separate sheet of paper with your National Insurance number written on it.
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Q32. What hospital, clinic or special treatments are you getting?
Guidance: For example, the treatment you are having, where you get it and how often. If you are expecting to have treatment in the near future, tell us what the treatment will be and the date it is due to start.
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Q33. Are you having or waiting for any treatment which needs you to stay somewhere overnight or longer?
Options: No; Yes
Guidance: Tell us about this. Go to ‘How your conditions affect eating and drinking’
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Q34. Are you in, or due to start a residential rehabilitation scheme?
Options: No; Yes
Guidance: Tell us the name of the organisation running your scheme. When your treatment began, or is due to begin. When you expect it to end. If you need more space, please use the ‘Other information’ section on page 20 or a separate sheet of paper with your National Insurance number written on it.
How your conditions affect eating and drinking
Q35. Can you get food or drink to your mouth without help or being prompted by another person?
Options: No; Yes; It varies
Guidance: If you have answered No or It varies, tell us about how you eat or drink and why you might need help.
How your conditions affect eating and drinking
Q36. Can you chew and swallow food or drink without help or being prompted by another person?
Options: No; Yes; It varies
How your conditions affect eating and drinking
Q37. If you have answered No or It varies, tell us about how you eat or drink and why you might need help.
How your conditions affect your physical health capabilities
Q38. Can you move around and use steps without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 43
How your conditions affect your physical health capabilities
Q39. How far can you move safely and repeatedly on level ground without needing to stop?
Options: 50 metres - this is about the length of 5 double-decker buses, or twice the length of an average public swimming pool; 100 metres - this is about the length of a football pitch; 200 metres or more
How your conditions affect your physical health capabilities
Q40. Tell us how far you can move and why you might have to stop. If you usually use a walking stick, crutches, a wheelchair or anything else to help you, tell us how it affects the way you move around.
How your conditions affect your physical health capabilities
Q41. Can you go up or down 2 steps without help from another person, if there is a rail to hold on to?
Options: No; Yes; It varies
Guidance: Go to question 43
How your conditions affect your physical health capabilities
Q42. If you have answered No or It varies, tell us more about using steps.
How your conditions affect your physical health capabilities
Q43. Can you stand and sit without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 47
How your conditions affect your physical health capabilities
Q44. Can you move from one seat to another right next to it without help from someone else?
Options: No; Yes; It varies
How your conditions affect your physical health capabilities
Q45. While you are standing or sitting (or a combination of the two) how long can you stay in one place without help from another person?
Options: Less than 30 minutes; 30 minutes to 1 hour; More than 1 hour; It varies
How your conditions affect your physical health capabilities
Q46. If you have problems with standing and sitting, tell us more about it. Tell us why this might be difficult for you and how this affects your typical day. Please include how long you can sit for, how long you can stand for and what might make sitting and standing difficult for you.
How your conditions affect your physical health capabilities
Q47. Can you reach up with either of your arms without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 51
How your conditions affect your physical health capabilities
Q48. Can you lift at least one of your arms high enough to put something in the top pocket of a coat or jacket while you are wearing it?
Options: No; Yes; It varies
Guidance: Go to question 56
How your conditions affect your physical health capabilities
Q49. Can you lift at least one of your arms above your head?
Options: No; Yes; It varies
Guidance: Go to question 51
How your conditions affect your physical health capabilities
Q50. If you have answered No or It varies, tell us why you might not be able to reach up and if this affects both arms.
How your conditions affect your physical health capabilities
Q51. Can you pick things up and move them without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 56
How your conditions affect your physical health capabilities
Q52. Can you pick up and move a half-litre (1 pint) carton full of liquid at waist height using your upper body and arms?
Options: No; Yes; It varies
How your conditions affect your physical health capabilities
Q53. Can you pick up and move a litre (2 pint) carton full of liquid at waist height using your upper body and arms?
Options: No; Yes; It varies
How your conditions affect your physical health capabilities
Q54. Can you pick up and move a large, light object like an empty cardboard box?
Options: No; Yes; It varies
Guidance: For example, from one surface to another at waist height.
How your conditions affect your physical health capabilities
Q55. If you have answered No or It varies, tell us more about picking things up and moving them and why you might not be able to pick things up.
How your conditions affect your physical health capabilities
Q56. Can you use your hands without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘How your conditions affect communication’
How your conditions affect your physical health capabilities
Q57. Can you use either hand to press a button (such as a telephone keypad), turn the pages of a book, pick up a £1 coin, use a pen or pencil or use a suitable keyboard or mouse?
Options: Some of these things; None of these things; It varies
How your conditions affect your physical health capabilities
Q58. If you have answered Some of these things or It varies, tell us which of these things you have problems with and why. If it varies, tell us how.
How your conditions affect communication
Q59. Can you communicate with other people without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Communicating - hearing and reading’
How your conditions affect communication
Q60. Can you communicate a simple message to other people such as the presence of something dangerous?
Options: No; Yes; It varies
Guidance: This can be by speaking, writing, typing or any other means, but without the help of another person.
How your conditions affect communication
Q61. If you have answered No or It varies, tell us how you communicate and why you might not be able to communicate with other people.
Guidance: For example, difficulties with speech, writing or typing.
How your conditions affect communication
Q62. Can you understand other people without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Getting around safely’
How your conditions affect communication
Q63. Can you understand simple messages from other people by hearing or lip reading without the help of your vision?
Options: No; Yes; It varies
Guidance: A simple message means things like someone telling you the location of a fire escape.
How your conditions affect communication
Q64. Can you understand simple messages from other people by reading braille or large print (Arial size 16 or larger)?
Options: No; Yes; It varies
How your conditions affect communication
Q65. If you have answered No or It varies, tell us more about if you need to communicate in another way or use aids, such as a hearing aid.
Getting around safely
Q66. Can you get around safely on your own?
Options: No; Yes; It varies
Guidance: Go to ‘How your conditions affect your physical functions’
Getting around safely
Q67. Can you see to cross the road safely on your own?
Options: No; Yes; It varies
Getting around safely
Q68. Can you safely get around a place that you have not been to before without help?
Options: No; Yes; It varies
Getting around safely
Q69. If you have answered No or It varies, tell us about your eyesight and any problems you have finding your way around safely.
How your conditions affect your physical functions
Q70. Can you control your bowels and bladder without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Staying conscious when awake’
How your conditions affect your physical functions
Q71. Do you have to wash or change your clothes because of difficulty controlling your bladder, bowels or collecting device?
Options: No; Yes - weekly; Yes - monthly; Yes - less than a month; Yes - but only if I cannot reach a toilet quickly
How your conditions affect your physical functions
Q72. Tell us about: • any difficulty you have controlling your bowels and bladder or managing your collecting device • problems you have if you cannot reach a toilet quickly • any aids you use such as incontinence pads.
Staying conscious when awake
Q73. Do you have any problems staying conscious while awake?
Options: No; Yes; It varies
Guidance: Go to ‘How your conditions affect your mental, cognitive and intellectual capabilities’
Staying conscious when awake
Q74. While you are awake, how often do you faint or have fits or blackouts?
Options: Daily; Weekly; Monthly; Less than monthly
Guidance: This includes epileptic seizures such as fits, partial or focal seizures, absences and diabetic hypos.
Staying conscious when awake
Q75. Tell us about your fainting, fits or blackouts.
Learning how to do tasks
Q76. Can you learn to do everyday tasks without difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Awareness of hazards or danger’
Learning how to do tasks
Q77. Can you learn how to do an everyday task such as setting an alarm on a clock or smartphone?
Options: No; Yes; It varies
Guidance: Go to ‘Awareness of hazards or danger’
Learning how to do tasks
Q78. Can you learn how to do a more complicated task such as using a washing machine?
Options: No; Yes; It varies
Guidance: Go to ‘Starting and finishing tasks’
Learning how to do tasks
Q79. If you have answered No or It varies, tell us about any difficulties you have learning to do tasks and why you find it difficult.
Awareness of hazards or danger
Q80. Can you stay safe when doing everyday tasks such as boiling water or using sharp objects?
Options: No; Yes; It varies
Guidance: Go to ‘Starting and finishing tasks’
Awareness of hazards or danger
Q81. Do you need someone to stay with you most of the time for you to stay safe?
Options: No; Yes; It varies
Guidance: Go to ‘Starting and finishing tasks’
Awareness of hazards or danger
Q82. If you have answered Yes or It varies, tell us about how you cope with danger and what problems you have with doing things safely.
Starting and finishing tasks
Q83. Can you manage to do daily tasks without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 86
Starting and finishing tasks
Q84. Can you manage to plan, start and finish daily tasks?
Options: No; Yes; It varies
Guidance: Go to question 86
Starting and finishing tasks
Q85. Tell us about what difficulties you have doing your daily routines. This means things like your bus or train planning and organising how to do them, and concentrating to finish them. Tell us what might make it difficult for you and how often you need other people to help you. If it varies, tell us how.
Coping with changes
Q86. Can you cope with changes to your daily routine?
Options: No; Yes; It varies
Guidance: Go to ‘Going out’
Coping with changes
Q87. Can you cope with small changes to your routine if you know about them before they happen?
Options: No; Yes; It varies
Guidance: For example, things like having a meal earlier or later than usual, or an appointment time being changed.
Coping with changes
Q88. Can you cope with small changes to your routine if they are unexpected?
Options: No; Yes; It varies
Coping with changes
Q89. If you have answered No or It varies, tell us more about how you cope with change. Explain your problems, and give examples if you can.
Going out
Q90. Can you go out on your own?
Options: No; Yes; It varies
Guidance: Go to ‘Coping with social situations’
Going out
Q91. Can you leave home and go out to places you know?
Options: No; Yes; Yes, if someone goes with me; It varies
Going out
Q92. Can you leave home and go to places you do not know?
Options: No; Yes; Yes, if someone goes with me; It varies
Going out
Q93. If you have answered No or It varies, tell us why you cannot always get to places and if you need someone to go with you. Explain your problems, and give examples if you can.
Coping with social situations
Q94. Can you cope with social situations without feeling too anxious or scared?
Options: No; Yes; It varies
Guidance: Go to ‘Behaving appropriately’
Coping with social situations
Q95. Can you meet people you know without feeling too anxious or scared?
Options: No; Yes; It varies
Guidance: Go to ‘Behaving appropriately’
Coping with social situations
Q96. Can you meet people you do not know without feeling too anxious or scared?
Options: No; Yes; It varies
Guidance: Go to ‘Behaving appropriately’
Coping with social situations
Q97. If you have answered No or It varies, tell us why you find it distressing to meet other people, what makes it difficult and how often you feel like this. If it varies, tell us how.
Behaving appropriately
Q98. Does your behaviour upset other people?
Options: No; Yes; It varies
Guidance: Go to ‘Work Capability Assessment’
Behaving appropriately
Q99. How often do you behave in a way which upsets other people?
Options: Every day; Frequently; Occasionally
Guidance: For example, this might be because your disability, illness or health condition results in you behaving aggressively or acting in an unusual way.
Behaving appropriately
Q100. Tell us or provide examples of how your behaviour upsets other people and how often this happens. Explain your problems, and give examples if you can.
Work Capability Assessment
Q101. If you need more space to answer any of the questions, please use the box below. Carers, friends or relatives can also add any information here about how your disability, illness or health condition affects how you can do things on a daily basis. Please complete page 4 with their contact details as we may want to contact them for more information. If you need more space, please use a separate sheet of paper with your National Insurance number written on it.
If you are returning this questionnaire late
Q102. Are you sending this questionnaire back later than the date we asked you to?
Options: No; Yes
Guidance: Please tell us why.
Cancer treatment
Q103. Details of cancer diagnosis Include the type and site, stage and any related diagnosis.
Guidance: A waiting or undergoing chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Recovering from (post completion of treatment) chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Please tick only if there is an ongoing prospect of further recovery or prospect of improvement?
Cancer treatment
Q104. Details of treatment Include the regime and expected duration.
Cancer treatment
Q105. Is your patient: A waiting or undergoing chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Recovering from (post completion of treatment) chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Please tick only if there is an ongoing prospect of further recovery or prospect of improvement?
Options: No; Yes
Cancer treatment
Q106. In your opinion, is it likely that the impact of the treatment has or will have work-limiting side effects?
Options: No; Yes
Guidance: Go to page 24
Cancer treatment
Q107. In your opinion, are these side effects likely to limit all work?
Options: No; Yes
Guidance: Go to page 24
Cancer treatment
Q108. In your opinion, how long would you expect these side effects to last?
Healthcare professional’s signature
Q109. Name
Healthcare professional’s signature
Q110. Signature
Guidance: Please sign the form here after printing.
Healthcare professional’s signature
Q111. Job title and qualifications
Healthcare professional’s signature
Q112. Date
Healthcare professional’s signature
Q113. Surgery stamp, hospital stamp or address details
Guidance: Please make sure page 23 is fully completed.
About you
Q1. First name
About you
Q2. Last name
About you
Q3. National Insurance (N I) number
Guidance: Your NI number can be found on the letter we have sent with this form.
About you
Q4. Address
About you
Q5. Mobile phone number, if you have one
More information about you
Q6. Date of birth
More information about you
Q7. Any other contact telephone numbers
More information about you
Q8. Your email address, if you have one
More information about you
Q9. Are you pregnant?
Options: No; Yes
Guidance: When is your baby due? This information will help us find your medical records more quickly. We will not share or use this information for any other purpose.
More information about you
Q10. Have you been in hospital for over 28 days in the last 12 months?
Options: No; Yes
Guidance: What date did you leave? Go to question 12
More information about you
Q11. Please tell us the dates you were in hospital. Give an approximate date if you cannot remember.
Guidance: From To Name and address of the hospital. Postcode
More information about you
Q12. Have you been released from prison in the last 6 months?
Options: No; Yes
For people filling in this questionnaire for someone else
Q13. Are you filling in the form for someone else?
Options: No; Yes
Guidance: Go to ‘About your General Practitioner (GP) or the doctor’s surgery’
For people filling in this questionnaire for someone else
Q14. Your first name
For people filling in this questionnaire for someone else
Q15. Your last name
For people filling in this questionnaire for someone else
Q16. Your address
For people filling in this questionnaire for someone else
Q17. A phone number we can contact you on
For people filling in this questionnaire for someone else
Q18. Why are you filling in the form for them?
Options: I am an appointee appointed by the Department for Work and Pensions (DWP); I am a Deputy; I am a Corporate Acting Body or Corporate Appointee; I am a carer; I am a friend/relative; Other
Guidance: Please tell us your connection to the person the questionnaire is about and why you are filling in this questionnaire for them.
About your General Practitioner (GP) or doctor’s surgery
Q19. Tell us either your GP’s name or the name of the doctor’s surgery you attend, or both if known.
About your General Practitioner (GP) or doctor’s surgery
Q20. Their phone number
About your General Practitioner (GP) or doctor’s surgery
Q21. Their address
About other healthcare professionals, carers, friends or relatives
Q22. Their name
About other healthcare professionals, carers, friends or relatives
Q23. Their job title
About other healthcare professionals, carers, friends or relatives
Q24. Their phone number
About other healthcare professionals, carers, friends or relatives
Q25. Their address
Sharing information about your disability, illness or health condition
Q26. Do you give consent for your doctor or other relevant professionals to give DWP more information about your disability, illness or health condition?
Options: Yes - I have read and understood how DWP uses information and agree information about my health can be shared with DWP or the healthcare professionals that work for DWP.; No - Information about my health cannot be shared with DWP or the healthcare professionals that work for DWP.
Cancer treatment
Q27. Have you been diagnosed with cancer?
Options: No; Yes
Guidance: Go to ‘About your disabilities, illness or health conditions’
Cancer treatment
Q28. Are you having, waiting for or recovering from any of the following treatment for cancer?
Options: • chemotherapy; • biological treatment/immunotherapy; • hormonal treatment; • targeted therapy, or; • radiotherapy.
Guidance: If you are having, waiting for or recovering from any of the cancer treatments listed in question 28, please make sure pages 23 and 24 are filled in and signed by your healthcare professional. This may include a GP (who may charge a fee), hospital doctor or clinical nurse who is aware of your cancer treatment.
Cancer treatment
Q29. Do you have other health problems, as well as cancer and the problems resulting from your cancer treatment?
Options: No; Yes
Guidance: If you have other health problems as well as cancer and the problems resulting from your cancer treatment, please fill in the rest of the form as well as page 23. When your healthcare professional has signed page 24 and you have signed page 21 you can then return this questionnaire using the enclosed envelope.
About your disabilities, illness or health conditions
Q30. What are your disabilities, illness or health conditions?
Guidance: Tell us how they affect you, when they started and if you think any of your conditions are linked to drugs or alcohol. Also tell us about any aids you use, such as a wheelchair or hearing aid and anything else you think we should know about your disabilities, illness or health conditions. Name of your condition, illness or disability and how it affects you Any aids you use for your condition, illness or disability Approximate start date
About your disabilities, illness or health conditions
Q31. What tablets, liquids, inhalers or other medication are you taking and are there any side effects?
Guidance: Tell us about tablets or other medication you are taking and the dosage. If you are sending in a copy of your prescription, please tell us about the side affects. Medication Dosage How often do you take it? Do you have any side effects? Example - Paracetamol 500mg Twice a day Dizziness If you need more space, please use the ‘Other information’ section on page 20 or a separate sheet of paper with your National Insurance number written on it.
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Q32. What hospital, clinic or special treatments are you getting?
Guidance: For example, the treatment you are having, where you get it and how often. If you are expecting to have treatment in the near future, tell us what the treatment will be and the date it is due to start.
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Q33. Are you having or waiting for any treatment which needs you to stay somewhere overnight or longer?
Options: No; Yes
Guidance: Tell us about this. Go to ‘How your conditions affect eating and drinking’
Hospital, clinic or special treatment like dialysis or rehabilitation treatment
Q34. Are you in, or due to start a residential rehabilitation scheme?
Options: No; Yes
Guidance: Tell us the name of the organisation running your scheme. When your treatment began, or is due to begin. When you expect it to end. If you need more space, please use the ‘Other information’ section on page 20 or a separate sheet of paper with your National Insurance number written on it.
How your conditions affect eating and drinking
Q35. Can you get food or drink to your mouth without help or being prompted by another person?
Options: No; Yes; It varies
Guidance: If you have answered No or It varies, tell us about how you eat or drink and why you might need help.
How your conditions affect eating and drinking
Q36. Can you chew and swallow food or drink without help or being prompted by another person?
Options: No; Yes; It varies
How your conditions affect eating and drinking
Q37. If you have answered No or It varies, tell us about how you eat or drink and why you might need help.
How your conditions affect your physical health capabilities
Q38. Can you move around and use steps without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 43
How your conditions affect your physical health capabilities
Q39. How far can you move safely and repeatedly on level ground without needing to stop?
Options: 50 metres - this is about the length of 5 double-decker buses, or twice the length of an average public swimming pool; 100 metres - this is about the length of a football pitch; 200 metres or more
How your conditions affect your physical health capabilities
Q40. Tell us how far you can move and why you might have to stop. If you usually use a walking stick, crutches, a wheelchair or anything else to help you, tell us how it affects the way you move around.
How your conditions affect your physical health capabilities
Q41. Can you go up or down 2 steps without help from another person, if there is a rail to hold on to?
Options: No; Yes; It varies
Guidance: Go to question 43
How your conditions affect your physical health capabilities
Q42. If you have answered No or It varies, tell us more about using steps.
How your conditions affect your physical health capabilities
Q43. Can you stand and sit without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 47
How your conditions affect your physical health capabilities
Q44. Can you move from one seat to another right next to it without help from someone else?
Options: No; Yes; It varies
How your conditions affect your physical health capabilities
Q45. While you are standing or sitting (or a combination of the two) how long can you stay in one place without help from another person?
Options: Less than 30 minutes; 30 minutes to 1 hour; More than 1 hour; It varies
How your conditions affect your physical health capabilities
Q46. If you have problems with standing and sitting, tell us more about it. Tell us why this might be difficult for you and how this affects your typical day. Please include how long you can sit for, how long you can stand for and what might make sitting and standing difficult for you.
How your conditions affect your physical health capabilities
Q47. Can you reach up with either of your arms without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 51
How your conditions affect your physical health capabilities
Q48. Can you lift at least one of your arms high enough to put something in the top pocket of a coat or jacket while you are wearing it?
Options: No; Yes; It varies
Guidance: Go to question 56
How your conditions affect your physical health capabilities
Q49. Can you lift at least one of your arms above your head?
Options: No; Yes; It varies
Guidance: Go to question 51
How your conditions affect your physical health capabilities
Q50. If you have answered No or It varies, tell us why you might not be able to reach up and if this affects both arms.
How your conditions affect your physical health capabilities
Q51. Can you pick things up and move them without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 56
How your conditions affect your physical health capabilities
Q52. Can you pick up and move a half-litre (1 pint) carton full of liquid at waist height using your upper body and arms?
Options: No; Yes; It varies
How your conditions affect your physical health capabilities
Q53. Can you pick up and move a litre (2 pint) carton full of liquid at waist height using your upper body and arms?
Options: No; Yes; It varies
How your conditions affect your physical health capabilities
Q54. Can you pick up and move a large, light object like an empty cardboard box?
Options: No; Yes; It varies
Guidance: For example, from one surface to another at waist height.
How your conditions affect your physical health capabilities
Q55. If you have answered No or It varies, tell us more about picking things up and moving them and why you might not be able to pick things up.
How your conditions affect your physical health capabilities
Q56. Can you use your hands without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘How your conditions affect communication’
How your conditions affect your physical health capabilities
Q57. Can you use either hand to press a button (such as a telephone keypad), turn the pages of a book, pick up a £1 coin, use a pen or pencil or use a suitable keyboard or mouse?
Options: Some of these things; None of these things; It varies
How your conditions affect your physical health capabilities
Q58. If you have answered Some of these things or It varies, tell us which of these things you have problems with and why. If it varies, tell us how.
How your conditions affect communication
Q59. Can you communicate with other people without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Communicating - hearing and reading’
How your conditions affect communication
Q60. Can you communicate a simple message to other people such as the presence of something dangerous?
Options: No; Yes; It varies
Guidance: This can be by speaking, writing, typing or any other means, but without the help of another person.
How your conditions affect communication
Q61. If you have answered No or It varies, tell us how you communicate and why you might not be able to communicate with other people.
Guidance: For example, difficulties with speech, writing or typing.
How your conditions affect communication
Q62. Can you understand other people without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Getting around safely’
How your conditions affect communication
Q63. Can you understand simple messages from other people by hearing or lip reading without the help of your vision?
Options: No; Yes; It varies
Guidance: A simple message means things like someone telling you the location of a fire escape.
How your conditions affect communication
Q64. Can you understand simple messages from other people by reading braille or large print (Arial size 16 or larger)?
Options: No; Yes; It varies
How your conditions affect communication
Q65. If you have answered No or It varies, tell us more about if you need to communicate in another way or use aids, such as a hearing aid.
Getting around safely
Q66. Can you get around safely on your own?
Options: No; Yes; It varies
Guidance: Go to ‘How your conditions affect your physical functions’
Getting around safely
Q67. Can you see to cross the road safely on your own?
Options: No; Yes; It varies
Getting around safely
Q68. Can you safely get around a place that you have not been to before without help?
Options: No; Yes; It varies
Getting around safely
Q69. If you have answered No or It varies, tell us about your eyesight and any problems you have finding your way around safely.
How your conditions affect your physical functions
Q70. Can you control your bowels and bladder without any difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Staying conscious when awake’
How your conditions affect your physical functions
Q71. Do you have to wash or change your clothes because of difficulty controlling your bladder, bowels or collecting device?
Options: No; Yes - weekly; Yes - monthly; Yes - less than a month; Yes - but only if I cannot reach a toilet quickly
How your conditions affect your physical functions
Q72. Tell us about: • any difficulty you have controlling your bowels and bladder or managing your collecting device • problems you have if you cannot reach a toilet quickly • any aids you use such as incontinence pads.
Staying conscious when awake
Q73. Do you have any problems staying conscious while awake?
Options: No; Yes; It varies
Guidance: Go to ‘How your conditions affect your mental, cognitive and intellectual capabilities’
Staying conscious when awake
Q74. While you are awake, how often do you faint or have fits or blackouts?
Options: Daily; Weekly; Monthly; Less than monthly
Guidance: This includes epileptic seizures such as fits, partial or focal seizures, absences and diabetic hypos.
Staying conscious when awake
Q75. Tell us about your fainting, fits or blackouts.
Learning how to do tasks
Q76. Can you learn to do everyday tasks without difficulty?
Options: No; Yes; It varies
Guidance: Go to ‘Awareness of hazards or danger’
Learning how to do tasks
Q77. Can you learn how to do an everyday task such as setting an alarm on a clock or smartphone?
Options: No; Yes; It varies
Guidance: Go to ‘Awareness of hazards or danger’
Learning how to do tasks
Q78. Can you learn how to do a more complicated task such as using a washing machine?
Options: No; Yes; It varies
Guidance: Go to ‘Starting and finishing tasks’
Learning how to do tasks
Q79. If you have answered No or It varies, tell us about any difficulties you have learning to do tasks and why you find it difficult.
Awareness of hazards or danger
Q80. Can you stay safe when doing everyday tasks such as boiling water or using sharp objects?
Options: No; Yes; It varies
Guidance: Go to ‘Starting and finishing tasks’
Awareness of hazards or danger
Q81. Do you need someone to stay with you most of the time for you to stay safe?
Options: No; Yes; It varies
Guidance: Go to ‘Starting and finishing tasks’
Awareness of hazards or danger
Q82. If you have answered Yes or It varies, tell us about how you cope with danger and what problems you have with doing things safely.
Starting and finishing tasks
Q83. Can you manage to do daily tasks without difficulty?
Options: No; Yes; It varies
Guidance: Go to question 86
Starting and finishing tasks
Q84. Can you manage to plan, start and finish daily tasks?
Options: No; Yes; It varies
Guidance: Go to question 86
Starting and finishing tasks
Q85. Tell us about what difficulties you have doing your daily routines. This means things like your bus or train planning and organising how to do them, and concentrating to finish them. Tell us what might make it difficult for you and how often you need other people to help you. If it varies, tell us how.
Coping with changes
Q86. Can you cope with changes to your daily routine?
Options: No; Yes; It varies
Guidance: Go to ‘Going out’
Coping with changes
Q87. Can you cope with small changes to your routine if you know about them before they happen?
Options: No; Yes; It varies
Guidance: For example, things like having a meal earlier or later than usual, or an appointment time being changed.
Coping with changes
Q88. Can you cope with small changes to your routine if they are unexpected?
Options: No; Yes; It varies
Coping with changes
Q89. If you have answered No or It varies, tell us more about how you cope with change. Explain your problems, and give examples if you can.
Going out
Q90. Can you go out on your own?
Options: No; Yes; It varies
Guidance: Go to ‘Coping with social situations’
Going out
Q91. Can you leave home and go out to places you know?
Options: No; Yes; Yes, if someone goes with me; It varies
Going out
Q92. Can you leave home and go to places you do not know?
Options: No; Yes; Yes, if someone goes with me; It varies
Going out
Q93. If you have answered No or It varies, tell us why you cannot always get to places and if you need someone to go with you. Explain your problems, and give examples if you can.
Coping with social situations
Q94. Can you cope with social situations without feeling too anxious or scared?
Options: No; Yes; It varies
Guidance: Go to ‘Behaving appropriately’
Coping with social situations
Q95. Can you meet people you know without feeling too anxious or scared?
Options: No; Yes; It varies
Guidance: Go to ‘Behaving appropriately’
Coping with social situations
Q96. Can you meet people you do not know without feeling too anxious or scared?
Options: No; Yes; It varies
Guidance: Go to ‘Behaving appropriately’
Coping with social situations
Q97. If you have answered No or It varies, tell us why you find it distressing to meet other people, what makes it difficult and how often you feel like this. If it varies, tell us how.
Behaving appropriately
Q98. Does your behaviour upset other people?
Options: No; Yes; It varies
Guidance: Go to ‘Work Capability Assessment’
Behaving appropriately
Q99. How often do you behave in a way which upsets other people?
Options: Every day; Frequently; Occasionally
Guidance: For example, this might be because your disability, illness or health condition results in you behaving aggressively or acting in an unusual way.
Behaving appropriately
Q100. Tell us or provide examples of how your behaviour upsets other people and how often this happens. Explain your problems, and give examples if you can.
Work Capability Assessment
Q101. If you need more space to answer any of the questions, please use the box below. Carers, friends or relatives can also add any information here about how your disability, illness or health condition affects how you can do things on a daily basis. Please complete page 4 with their contact details as we may want to contact them for more information. If you need more space, please use a separate sheet of paper with your National Insurance number written on it.
If you are returning this questionnaire late
Q102. Are you sending this questionnaire back later than the date we asked you to?
Options: No; Yes
Guidance: Please tell us why.
Cancer treatment
Q103. Details of cancer diagnosis Include the type and site, stage and any related diagnosis.
Guidance: A waiting or undergoing chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Recovering from (post completion of treatment) chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Please tick only if there is an ongoing prospect of further recovery or prospect of improvement?
Cancer treatment
Q104. Details of treatment Include the regime and expected duration.
Cancer treatment
Q105. Is your patient: A waiting or undergoing chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Recovering from (post completion of treatment) chemotherapy, biological treatment/immunotherapy, hormonal treatment, targeted therapy or radiotherapy treatment for cancer Please tick only if there is an ongoing prospect of further recovery or prospect of improvement?
Options: No; Yes
Cancer treatment
Q106. In your opinion, is it likely that the impact of the treatment has or will have work-limiting side effects?
Options: No; Yes
Guidance: Go to page 24
Cancer treatment
Q107. In your opinion, are these side effects likely to limit all work?
Options: No; Yes
Guidance: Go to page 24
Cancer treatment
Q108. In your opinion, how long would you expect these side effects to last?
Healthcare professional’s signature
Q109. Name
Healthcare professional’s signature
Q110. Signature
Guidance: Please sign the form here after printing.
Healthcare professional’s signature
Q111. Job title and qualifications
Healthcare professional’s signature
Q112. Date
Healthcare professional’s signature
Q113. Surgery stamp, hospital stamp or address details
Guidance: Please make sure page 23 is fully completed.