Questions 1-11 About you

Personal information about you (the Claimant). You must normally live in Great Britain and have lived there for 26 weeks before you can claim.

Question 12 Signing the form

The form can be filled in for another adult but they must still sign it themselves unless you hold a Power of Attorney, or act as Deputy for them under the Court of Protection, or if you are an appointee by the DWP, or they cannot manage their affairs due to a mental health problem or learning disability, or if they are so ill or disabled it is impossible to sign themselves or if you are claiming under the special rules (see Question 18).

In Scotland you must be judicial factor, guardian, tutor or curator bonis appointed under Scottish law.

Questions 13 - 22 About your illnesses or disabilities and the treatment or help you receive.

Include information about all your illnesses and disabilities, for example you may have renal failure and diabetes and arthritis. Also include problems which are commonly experienced by kidney patients, if you experience these problems or indeed any others then you should declare them on the application form. Give a history of your renal failure and the periods of time you are on dialysis.

List all prescribed medicines, tablets and other treatments. Record how long you have been taking it, it is a repeat prescription and what the dosage and frequency is. Then list all of the over-the-counter medications that you take.

Remember, other treatments includes dialysis and any special diet and any dietary supplements.

If in doubt – include it.

For people on kidney dialysis

Complete this section with details of the hospital who arranges dialysis for you – the Benefits Agency will write to you about this.

Your hospital doctor or specialist

List all hospital doctors or specialists you have seen in the last 12 months, include appointments for all conditions.

These questions are about how your illnesses and disabilities affect you. Illnesses and disabilities can affect people more on one day than another and also can vary over a period of time or in different conditions.

You should refer to help you need with social, hobby and leisure activities. It should include the things you would do or places you would go if you had help or assistance.

Some activities may be ones you only carry out occasionally but don’t be put off by this.

One of the ways people manage an illness or disability is to focus on the positive aspects. They tend to adopt an “I can do it” attitude and indeed, this approach and independence is widely recommended and encouraged in helping you deal with the psychological aspects of kidney failure.

However, when applying for DLA, you need to put this attitude and approach to one side and look at activities and how you cope with them from a different angle – one which focuses on the help, assistance or care you need from someone else, regardless of whether there is anyone there to actually help you.

When you complete the application do not minimise your illnesses and disabilities and do not underestimate the amount of time or how often you need help. The information you give will have an impact on the claim being awarded or turned down. Kidney failure causes problems for the rest of the body and it is important to mention everything that affects your well-being. The more information you provide, the better.

List any aids and adaptations you use with or without help from health care professionals.

Questions 23 – 34 Getting around outdoors

Walking Outdoors

This is walking outdoors on level ground. You should consider though how many “obstacles” there may be in an ordinary street e.g. uneven pavements and kerbs when crossing the road.

• There are no guidelines issued as to how far you should be able to walk or how long it should take you to make this count towards your claim. If you can, get someone to help measure the distance and record the time. Do this on a number of occasions, when you feel at your worst and your best and remember that the time is an average so take an average of the distance you walked and the time it took you. If you can’t find someone to help you measure the distance, estimate it as closely as possible. If you have to stop to get your breath or you wouldn’t be able to continue walking the distance again without a rest then write this beside the box so it’s recorded
• How do you feel following haemodialyis? Do you feel weak and unsteady? Do you feel faint or sick? Does walking after dialysis give severe discomfort and breathlessness?
• Does peritoneal dialysis make you feel bloated or heavy? Does this make for severe discomfort or breathlessness?
• Are you 100% fit after a transplant or still tired? Do you get out of breath easily? Do you suffer from arthritis, osteoporosis or gout?
• Does your renal diet mean that you are malnourished and therefore feel weak?
• Is your mobility restricted due to stress, fatigue, exhaustion, breathlessness, dizziness, aching legs, muscle weakness, poor balance and falls? Can you only walk short distances before stopping to rest a while before you carry on walking? Have you lost feeling in your toes (a diabetic problem) and are at risk of stubbing your toes?
• Do you suffer from spasms or leg cramps that can suddenly come on when you’re walking outdoors?
• What effect does walking have on you after you have done it? Do you have to lie down and rest or are you in pain the next day and feel unable to move around at all? Do you ache afterwards and feel unable to carry out other tasks?

Falls or stumbles

• Falls and stumbles are dangerous to you and eligibility for DLA is based on what help you need to avoid this danger. Even if you do cope on your own, this is about what help you would get if it was available. You may be prone to falls and stumbles when you are carrying out certain activities, think what these could be for you. Some examples may be going to the supermarket; getting on and off a bus or getting in and out of a car.
• Think about the areas that you have fallen or stumbled and areas where you are particularly careful because you recognise that it is a potential hazard. If there are activities or places that you avoid because you know you are likely to fall or stumble then write this down
• DLA is about getting help for you. If they can make suggestions like telling you to avoid a certain activity and it is a reasonable suggestion or recommendation then this may go against this part of your claim. It may be that they would look at where you fall or stumble and suggest that you take action in the home to prevent you harming yourself should you fall. For example, they could recommend that you put “bumpers” on sharp edges so you don’t hurt yourself if you fall or even remove certain items from the home that are considered hazards if you fall on them.

Having someone with you when you are outdoors

You need to put yourself in the position of being in a strange place and consider if you would need to be helped in this situation. If you do need someone with you even in familiar places then this should be included too.

• Do you feel restricted due to stress?
• Do you have sudden bouts of fatigue where you would need help in finding somewhere to rest before continuing walking?
• How do you feel following dialysis? Are you faint or feeling sick? Do you suffer from leg cramps that can come on at any time? Do you become dizzy, weak or exhausted easily?
• Are you short sighted and need help crossing roads or maybe you can’t hear approaching traffic?
• Do you need help getting in and out of cars or on and off buses?
• Include in your answer if it would be impractical or unreasonable to remove items or activities from your day to day life.
• How do you feel following haemodialysis? Are you at any time faint, dizzy or light-headed, do you have poor balance, does this sometimes lead to you falling or stumbling?
• Does your medication have side-effects that make you feel dizzy and liable to stumble or fall?
• Do you suffer from spasms or leg cramps that can suddenly come on when you’re walking outdoors and lead you to fall or stumble?
• Is your mobility restricted due to stress, fatigue, exhaustion, breathlessness, dizziness, aching legs, muscle weakness, poor balance and falls?

Questions 35-48 Your care needs during the day

This also includes evening activities and refers to help you need with social, hobby and leisure activities. Indoors doesn’t just mean at home, it can be your place of work or places that you visit. Examples could be a library, place of worship, restaurant, cinema or theatre; indeed anywhere you go that is not “outdoors”.

• Are you slow at getting out of bed or your chair? Do you need someone to help support you when you do this?
• Do you need assistance getting into/out of bed or a chair to help you avoid falling or stumbling?
• Do you hold onto furniture to steady you?
• Do you have difficulty on the stairs? Do they make you breathless? Do you need to rest part-way on a normal length staircase?
• Are you slow at getting out of bed – do you lie awake for a while putting off getting out of bed because of the pain you are in or because you are stiff?
• Are you dizzy or light-headed when you wake up so have difficulty getting out of bed until this has passed?
• Is it difficult to get into bed because of pain or stiffness, do you need help to lower yourself onto the bed? Do you need help to swing your legs around to get them into bed?
• Do you have difficulty pulling up the covers or removing them again? Are your hands weak or arthritic so you would need help to do this?
• Are you able to adjust your pillows? Are your hands weak or arthritic so you would need help to do this?
• Do you need to get out of bed gradually – first to a sitting position and then standing until you can get your balance?

Getting out of bed in the morning and into bed at night

The DWP definition of night is when your household has closed down at the end of the day.

• Are you slow at getting out of bed – do you lie awake for a while putting off getting out of bed because of the pain you are in or because you are stiff?
• Are you dizzy or light-headed when you wake up so have difficulty getting out of bed until this has passed?
• Is it difficult to get into bed because of pain or stiffness, do you need help to lower yourself onto the bed? Do you need help to swing your legs around to get them into bed?
• Do you have difficulty pulling up the covers or removing them again? Are your hands weak or arthritic so you would need help to do this?
• Are you able to adjust your pillows? Are your hands weak or arthritic so you would need help to do this?
• Do you need to get out of bed gradually – first to a sitting position and then standing until you can get your balance?

When you are in bed

Do you suffer from itchy skin? Does it disturb your sleep? Do you need help applying cream to ease the itching so allowing you to sleep?

• How do you feel following haemodialysis? Do you feel faint or sick? If you have disturbed sleep following on from dialysis this should be included.
• Are you an APD patient who dialyses during the night and may require help?
• Do you suffer from cramps, spasms or restless legs? Do you need someone to help by massaging your leg before you can return to sleep?
• Is it difficult or painful to turn over?
• Do you find that you are in and out of bed through the night because of the pain?
• Do you need help to get out of bed to go to the toilet?
• Do you find that you can only lie in one position in bed and this makes you stiff and the pain worse?

Help with your toilet needs

This question covers both daytime and night-time requirements.

By “toilet needs” you should think not only about getting to and from the toilet, but also getting on and off the toilet, fastening or unfastening clothes, sometimes not making it to the toilet because of continence or mobility problems or wiping or cleaning yourself afterwards.

If the Benefits Agency felt it would be better for you to use a commode during the night but you feel this is not practical or unreasonable then you should include this in your answer.

• Do you have difficulty getting to and from the lavatory?
• Do you have difficulty getting on and off the toilet?
• Are your hands weak or arthritic and you need help with your clothes?

Washing, bathing and looking after your appearance

Problems with these activities start from getting to bathroom and should include all activities that you undertake whilst in the bathroom, including any problems you may have with sanitary protection for periods.

• Do you have problems undressing/dressing? (See also Page 11)
• Do you have difficulties getting in and out of the bath/shower?
• Do you have difficulties turning taps on and off?
• Do you have difficulty washing your hair, shaving, brushing your teeth, doing your hair - including using a hairdryer?
• Are your movements slow, do you feel weak and unbalanced so that you need someone to watch over you because you are in danger of slipping and hurting yourself?
• Are you anxious about keeping a catheter/line dry and avoid showering/bathing?
• As a PD patient, do you need help to meticulously clean your exit site to prevent peritonitis or other infections?

Getting dressed or undressed

If you have problems with fastenings the Benefits Agency could suggest that you always wear pull on clothes or slip on shoes. If this is unreasonable to you as you would have to buy an entirely new wardrobe then you should address this in your answer.

• Do you have problems undressing/dressing?
• Are you very slow at getting dressed/undressed?
• Can you lift your arms to get clothes over your head?
• Can you bend down to put on socks and shoes?
• Are your fingers numb or stiff so that you cannot fasten buttons?
• Do you feel too exhausted to dress?

Moving around indoors

• Falls and stumbles are dangerous to you and eligibility for DLA is based on what help you need to avoid this danger. Even if you do cope on your own, this is about what help you would get if it was available. You may be prone to falls and stumbles when you are carrying out certain activities, think what these could be for you. Some examples may be climbing stairs; getting in and out of a chair or bed; getting in and out of the bath or shower
• Think about the areas that you have fallen or stumbled and areas where you are particularly careful because you recognise that it is a potential hazard. If there are activities or places that you avoid because you know you are likely to fall or stumble then write this down
• DLA is about getting help for you. If they can make suggestions like telling you to avoid a certain activity and it is a reasonable suggestion or recommendation then this may go against this part of your claim. It may be that they would look at where you fall or stumble and suggest that you take action in the home to prevent you harming yourself should you fall. For example, they could recommend that you put “bumpers” on sharp edges so you don’t hurt yourself if you fall or even remove certain items from the home that are considered hazards if you fall on them.

Dizzy spells, blackouts, fits, seizures or something like this

• Do you suffer from dizzy spells due to dialysis?
• Is a side-effect of your medication dizziness?

Help with medical treatment

Medical treatment covers dialysis, prescription and over-the-counter drugs. You may also take dietary supplements which would be included in this.

• Do you undergo dialysis? Is this at home or in hospital? Do you need someone to supervise this or be in attendance whilst your dialysing?
• Is your concentration poor so that you need reminding when to take medicines?
• Are you able to establish which drugs you should not take?
• Do you forget you have taken tablets and take them twice?
• Do you have problems unscrewing bottles or getting into plastic containers?
• Do you need help applying creams or lotions for itchy skin?
• Do you need to have your limbs massaged because of cramps or restless legs?
• Do you have difficulties taking your own tests and monitoring treatment?
• Are your PD fluid bags heavy and you need help transferring them to their storage area, or from the storage area to the point of dialysis?
• Do you need help to rotate your fluid bag stocks to ensure they are used in date order?

The way you feel because of your mental health

Depression or anxiety is often experienced by people with long term health problems. Frequently, people do not seek help from their doctor for these problems. If you have difficulties with any tasks because of depression or anxiety you need to speak to your doctor and if possible provide evidence relating to your mental health for your claim.

Communicating with other people

As with Question 17, if you have difficulties communicating with people because of depression or anxiety you should seek help from your doctor for these problems.

Someone keeping an eye on you

As far as DLA is concerned, the reason you need someone with you must be to avoid substantial damage to yourself or to others. You should also refer back to Question 4 Having someone with you when you are outdoors and 5 Falls or stumbles.

Preparing a cooked main meal for yourself

This question refers to the preparation and cooking of a main meal for yourself – regardless of whether you do cook for yourself. You should consider this meal as a “meat and two veg” type dinner where you would be preparing and cooking different types of food.

• Is cooking hampered by poor concentration? Are you able to measure ingredients and follow instructions? Can you time everything to be cooked and ready at the same time? Do you sometimes forget when you have a pan on and need someone to remind you? Do you have difficulty choosing the ingredients for your renal diet?
• Do you find pans and dishes too heavy to lift safely? Is this because of dizziness or poor balance or because they feel too heavy for you to physically lift?
• Do you have difficulties turning taps on and off or using a tin-opener because your hands are stiff and swollen?
• Do you have problems cutting up vegetables or meat because of pain or stiffness?
• Do you have difficulties carrying your plate to the table, or a tray to your chair?

At mealtimes

Do you have a special diet and you need encouragement to stick to this? Does your renal diet mean that you are malnourished and therefore feel weak?

• Do you need help with planning your diet?
• Do you have oral problems (gum disease can be caused by drugs)?
• Do you have difficulty in chewing or swallowing?
• Do you feel nauseous so that you don’t want to eat?
• Are your hands weak or arthritic, do you feel pain holding and using cutlery or a cup or glass?
• Does the pain in your hands mean you have difficulty cutting up food on your plate?

Questions 49-52 Help with your care needs during the night

Getting out of bed in the morning and into bed at night

The DWP definition of night is when your household has closed down at the end of the day.

• Are you slow at getting out of bed – do you lie awake for a while putting off getting out of bed because of the pain you are in or because you are stiff?
• Are you dizzy or light-headed when you wake up so have difficulty getting out of bed until this has passed?
• Is it difficult to get into bed because of pain or stiffness, do you need help to lower yourself onto the bed? Do you need help to swing your legs around to get them into bed?
• Do you have difficulty pulling up the covers or removing them again? Are your hands weak or arthritic so you would need help to do this?
• Are you able to adjust your pillows? Are your hands weak or arthritic so you would need help to do this?
• Do you need to get out of bed gradually – first to a sitting position and then standing until you can get your balance?

When you are in bed

Do you suffer from itchy skin? Does it disturb your sleep? Do you need help applying cream to ease the itching so allowing you to sleep?

• How do you feel following haemodialysis? Do you feel faint or sick? If you have disturbed sleep following on from dialysis this should be included.
• Are you an APD patient who dialyses during the night and may require help?
• Do you suffer from cramps, spasms or restless legs? Do you need someone to help by massaging your leg before you can return to sleep?
• Is it difficult or painful to turn over?
• Do you find that you are in and out of bed through the night because of the pain?
• Do you need help to get out of bed to go to the toilet?
• Do you find that you can only lie in one position in bed and this makes you stiff and the pain worse?

Help with your toilet needs

This question covers both daytime and night-time requirements.

By “toilet needs” you should think not only about getting to and from the toilet, but also getting on and off the toilet, fastening or unfastening clothes, sometimes not making it to the toilet because of continence or mobility problems or wiping or cleaning yourself afterwards.

If the Benefits Agency felt it would be better for you to use a commode during the night but you feel this is not practical or unreasonable then you should include this in your answer.

• Do you have difficulty getting to and from the lavatory?
• Do you have difficulty getting on and off the toilet?
• Are your hands weak or arthritic and you need help with your clothes?

Someone keeping an eye on you

As far as DLA is concerned, the reason you need someone with you must be to avoid substantial damage to yourself or to others. You should also refer back to Question 4 Having someone with you when you are outdoors and 5 Falls or stumbles.

Questions 53- 54 Help with your Care Needs

This section may necessitate repeating information you have already supplied. Make sure you have covered all aspects of your care needs.

Washing, bathing and looking after your appearance

Problems with these activities start from getting to bathroom and should include all activities that you undertake whilst in the bathroom, including any problems you may have with sanitary protection for periods.

• Do you have problems undressing/dressing?
• Do you have difficulties getting in and out of the bath/shower?
• Do you have difficulties turning taps on and off?
• Do you have difficulty washing your hair, shaving, brushing your teeth, doing your hair - including using a hairdryer?
• Are your movements slow, do you feel weak and unbalanced so that you need someone to watch over you because you are in danger of slipping and hurting yourself?
• Are you anxious about keeping a catheter/line dry and avoid showering/bathing?
• As a PD patient, do you need help to meticulously clean your exit site to prevent peritonitis or other infections?

Getting dressed or undressed

If you have problems with fastenings the Benefits Agency could suggest that you always wear pull on clothes or slip on shoes. If this is unreasonable to you as you would have to buy an entirely new wardrobe then you should address this in your answer.

• Do you have problems undressing/dressing?
• Are you very slow at getting dressed/undressed?
• Can you lift your arms to get clothes over your head?
• Can you bend down to put on socks and shoes?
• Are your fingers numb or stiff so that you cannot fasten buttons?
• Do you feel too exhausted to dress?

Preparing a cooked main meal for yourself

This question refers to the preparation and cooking of a main meal for yourself – regardless of whether you do cook for yourself. You should consider this meal as a “meat and two veg” type dinner where you would be preparing and cooking different types of food.

• Is cooking hampered by poor concentration? Are you able to measure ingredients and follow instructions? Can you time everything to be cooked and ready at the same time? Do you sometimes forget when you have a pan on and need someone to remind you? Do you have difficulty choosing the ingredients for your renal diet?
• Do you find pans and dishes too heavy to lift safely? Is this because of dizziness or poor balance or because they feel too heavy for you to physically lift?
• Do you have difficulties turning taps on and off or using a tin-opener because your hands are stiff and swollen?
• Do you have problems cutting up vegetables or meat because of pain or stiffness?
• Do you have difficulties carrying your plate to the table, or a tray to your chair?

At mealtimes

• Do you have a special diet and you need encouragement to stick to this? Does your renal diet mean that you are malnourished and therefore feel weak?
• Do you need help with planning your diet?
• Do you have oral problems (gum disease can be caused by drugs)?
• Do you have difficulty in chewing or swallowing?
• Do you feel nauseous so that you don’t want to eat?
• Are your hands weak or arthritic, do you feel pain holding and using cutlery or a cup or glass?
• Does the pain in your hands mean you have difficulty cutting up food on your plate?

Help with medical treatment

Medical treatment covers dialysis, prescription and over-the-counter drugs. You may also take dietary supplements which would be included in this.

• Do you undergo dialysis? Is this at home or in hospital? Do you need someone to supervise this or be in attendance whilst your dialysing?
• Is your concentration poor so that you need reminding when to take medicines?
• Are you able to establish which drugs you should not take?
• Do you forget you have taken tablets and take them twice?
• Do you have problems unscrewing bottles or getting into plastic containers?
• Do you need help applying creams or lotions for itchy skin?
• Do you need to have your limbs massaged because of cramps or restless legs?
• Do you have difficulties taking your own tests and monitoring treatment?
• Are your PD fluid bags heavy and you need help transferring them to their storage area, or from the storage area to the point of dialysis?
• Do you need help to rotate your fluid bag stocks to ensure they are used in date order?

Someone keeping an eye on you both indoors and outdoors

As far as DLA is concerned, the reason you need someone with you must be to avoid substantial damage to yourself or to others. You should also refer back to Having someone with you when you are outdoors and Falls or stumbles.

Dizzy spells, blackouts, fits, seizures or something like this

• Do you suffer from dizzy spells due to dialysis?
• Is a side-effect of your medication dizziness?

The way you feel because of your mental health

Depression or anxiety is often experienced by people with long term health problems. Frequently, people do not seek help from their doctor for these problems. If you have difficulties with any tasks because of depression or anxiety you need to speak to your doctor and if possible provide evidence relating to your mental health for your claim.

Questions 55 – 57 About time spent in hospital, care home or a similar place

If you are awarded DLA when you are in hospital, care home or similar payment will not be made until you come out. If you are a private resident paying for your stay without help from public funds then you will receive payment.

Question 58 About other benefits

Other benefits are not normally affected

Question 59 How you are paid

Question 60 Statement from someone who knows you

Your family doctor or GP

The Benefits Agency may contact your GP. Make an appointment to see him to explain the process you are going through and give him an update on all of the problems you have. Include things like walking, dressing, cooking, eating, washing, etc. You might not have discussed these aspects and effects of your illness before and even if you have, the GP may not have recorded these problems so it is always prudent to make sure he has a complete overview of your situation before the Benefits Agency contact him. Doctors should be aware of the importance that their recorded opinions will have, if important information is omitted or if the doctor does not fully state the range and severity of your illness it may result in the Decision Makers making a decision not in the patient’s favour.

If possible get your GP/Specialist Doctor to fill this in for you. Take a photocopy of the blank page from the form so you can review the statement copy before you include it.

Make an appointment to see your GP or Specialist and explain the process you are going through and give him an update on all of the problems you have. On page 17 of this pack is a copy of a Briefing Paper, written by Dr Simon Jenkins MBE FRCGP, himself a renal patient, to assist doctors in completing DLA forms and in providing medical evidence for renal patients. Take this copy along to your doctor for his information.

If they can fill in the statement for you, there and then, all the better. But remember, Consultant are busy people, if they don’t have time then or if they want to write a report for you, ask them when it will be done and if you can collect it or have them send it.

If you are not happy with what the person has written, speak to them about what you disagree with and ask if they will re-write the statement. If they refuse, you can ask someone else to complete a statement. When you have a completed statement that you are happy with, attach this to your claim.

Question 61 Extra information

Make sure you have included all the information they should know about your claim

Question 62 Declaration

Read this page carefully and check your form before signing it.

What to do now:

Check that you have filled in every question that applies to you and that you have signed the Consent at Question 17 page 7 and the Declaration at Question 3 page 62. Make a list of all documents you are sending with your claim for example, a prescription list, medical report or care plan.

Do not forget to include your National Insurance Number.

Where to send the form:

If you are not sure where to send the form telephone the Benefits Enquiry Line on 0800 88 22 00. You need to return the form to the office that deals with the area where you live.

For an existing DLA claim you should contact

Disability Contact and Processing Unit
Warbreck House
Warbreck Hill
Blackpool
FY2 0YJ

Telephone 0845 712 3456

E-mail: DCPYU.Customer-services@dwp.gsi.gov.uk

Benefits Enquiry Line

This is a free advice line run by the Department of Work and Pensions

Telephone number : 0800 882 200

Lines open Monday to Friday 8.30am-6.30pm and Saturday 9.00am-1.00pm

Northern Ireland

Telephone number : 0800 220 674

Lines open Monday to Friday 9am-5pm

If you live in Northern Ireland you may find it useful to visit the Benefit Agency website for Northern Ireland on www.ssani.gov.uk which gives information about benefits.

Citizens Advice Bureau (CAB)

Free advice. See your phonebook for your nearest CAB office or search online at www.nacab.org.uk

Disability Alliance

The Disability Alliance produces a range of information about benefits

Telephone number: 0207 246 9776 or visit www.disabilityalliance.org

The Pension Service

The Government has set up The Pension Service to improve the service you receive, whether you are already a pensioner or are planning for your retirement, no matter how far off it might be.

The Pension Service has a network of pension centres. One central contact number connects you to the centre nearest to you.

The Pension Service was set up to:-

• Work out the amount of State Pension and Pension Credit that you are entitled to
• Tell you how you can access other pension-related entitlements and services
• Help with applying for benefits
• Work in partnership with other local organisations to deliver pension-related services

Telephone Number: 0845 60 60 265

Website: www.direct.gov.uk

National Kidney Federation Helpline

For advice on where to get help

Telephone: (0845) 601 02 09