Self assessment - Mobile

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"Enduring Condition" self-assessment

Please describe your medical conditions and disabilities which affect your mobility

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How does this condition/s affect your ability to access the community?

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How often do these conditions affect your walking?

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Permanently

Intermittently

Rarely

Never

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Have you recently had, or are waiting for, treatment or surgery in relation to your mobility issues?

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Yes

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Please describe all recent or planned treatment and how this will affect your mobility in the future

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Do you take prescribed medication for pain?

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Yes

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Please list all medications, with dosages and how often you take them

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Is the medication effective with managing your condition or disability?

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When I take my pain relief medication, I am able to cope with the pain.

Even after taking pain relief medication, I have to stop and take regular breaks.

Even after taking pain relief medication the pain makes me physically sick.

Even after taking pain relief medication, I am frequently in so much pain that walking for more than 2 minutes is unbearable.

Do you use any of these mobility aids or support?

Please leave all the options unticked if you don't use any of these

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Walking Stick

Walking / Wheeled Frame

Elbow Crutch(es)

Mobility Scooter

Oxygen

Prosthesis (due to loss of limb)

Support from family/friends

Adjustments to house to aid mobility such as ramps, grab rails, stair lift etc

Wheelchair bound ie: moving from wheelchair to chair/bed and unable to walk at all

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Please describe adjustments made to house to enhance mobility

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Which of the listed best describes how you walk outdoors?

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Upright / Steady

Unsteady

Unsteady with occasional falls

Unsteady with regular falls

Limp

Shuffle

Dragged limb

Stumble

Excessive labour

Are you troubled by breathlessness?

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Not at all

Walking up a hill or stairs

Trying to keep up with others on a level ground

Walking on level ground at my own pace

Getting dressed or trying to leave home

Do you take any prescribed medication for breathlessness, such as inhalers?

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Yes

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Please list all medications/inhalers, with dosages and how often you take them

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How far, in metres, can you walk comfortably without requiring recovery time, being in pain or short of breath? Please note, 80 metres is roughly the equivalent to 3 quarters of a full football pitch or 8 double decker buses.

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0-20 meters

21-40 meters

41-60 meters

61-80 meters

81-100 meters

101+ meters

Approximately how long, in minutes, would it take for you to walk 80 metres?

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Less than 1 minute

Between 1 & 1.5 minutes

Between 1.5 & 2 minutes

Longer than 2 minutes

Unable to walk 80 meters

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I can confirm I have explained where the customer can find the Blue Badge terms and conditions to read or have ensured these are included in follow up correspondence

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Further supporting documents

Please upload any other documents that support your application. If you have no further supporting documents, please press next.

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Please click 'choose file' to upload a supporting document

The maximum size file you can upload is 20MB. Acceptable file types: pdf, png, jpg, jpeg, doc, docx.

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Blue badge self assessment

"Enduring Condition" self-assessment

Further supporting documents