Disability Report Pre-Assessment

1 — About You

Basic details so we can match this to your record.

Full name *

Date of birth *

Phone number *

Email address

What type of report is this for? *

2 — Your Condition

Tell us about the condition(s) affecting your ability to work or carry out daily activities.

What condition(s) are you seeking this report for? *

List all conditions — physical and mental health.

How long have you had this condition? *

Do you expect your condition to improve?

Describe how your condition affects you day to day *

3 — How Your Condition Affects You

For each area below, select the option that best describes how your condition affects you on a typical day. Use the comment box to add any extra detail that would help your doctor.

💡 Good days and bad days: If your condition varies a lot, rate based on your average day — not your best day. You can explain the variation in the comment box.

🚶 Moving around / Walking

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Cannot do at all

🪜 Stairs and steps

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Cannot do at all

🤲 Using your hands and arms (gripping, lifting, reaching)

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Cannot do at all

🪑 Sitting or standing for periods of time

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Cannot do at all

⚡ Pain — location, frequency, and severity

🟢No pain

🟡Mild pain

🟠Moderate pain

🔴Severe pain

⛔Constant severe pain

😴 Tiredness and fatigue

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Cannot function

🧠 Mental health — anxiety, depression, mood

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Severely debilitating

💭 Memory and concentration

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Cannot retain information

🛁 Personal care (washing, dressing, eating, toileting)

🟢Fully independent

🟡Mostly independent

🟠Needs some help

🔴Needs regular help

⛔Fully dependent

🌙 Sleep

🟢Not affected

🟡Mildly disrupted

🟠Moderately disrupted

🔴Severely disrupted

⛔Unable to sleep

💬 Communication — speaking, understanding others

🟢Not affected

🟡Mildly affected

🟠Moderately affected

🔴Severely affected

⛔Unable to communicate

4 — Good Days and Bad Days

Many conditions vary significantly. Describe what a typical good day and a typical bad day look like for you.

☀️ Good day

🌧️ Bad day

How often do you have bad days?

5 — Daily Life and Work

What activities have you had to stop or significantly reduce because of your condition? *

Do you receive help from family members, carers, or others?

Current work / employment status

If not working, when did you last work?

6 — Medications

List the medications you are currently taking for your condition and whether they are helping.

Current medications for this condition

Do any medications cause side effects that affect your daily life?

7 — Supporting Documents

Tick any documents you currently have that are relevant to your condition. You don't need to send them now — your doctor will ask for them at your appointment if needed.

Any recent hospital admissions or specialist referrals?

8 — Anything Else

Is there anything else you would like your doctor to know when preparing your report?

1 — About You

2 — Your Condition

3 — How Your Condition Affects You

4 — Good Days and Bad Days

5 — Daily Life and Work

6 — Medications

7 — Supporting Documents

8 — Anything Else

Pre-assessment received