1. Personal Details Surname* Title* MrMrsMissMs First Name* D.O.B Address* Town* County* Post Code* Telephone No. Home Work Email* Holiday* 2. Name and address of your doctor Name Address Town County Post Code Tel Fax May we consult your doctor??  Yes  No 3. My disabling condition is PERSONAL ASSISTANCE - Please complete the following questions FULLY in order to ensure that your care needs are fulfilled. If you would like to add any further details, please do so on a separate sheet 4. Are you able to stand?  No  Yes with assistance  Yes without assistance 5. Are you able to bear your own weight when standing?  No  Yes with assistance  Yes without assistance 6. Are you able to transfer e.g. from wheelchair to toilet etc.  No  Yes with assistance  Yes without assistance 7. Can you walk?  No  Yes few steps with assistance  Yes few steps without assistance  Yes long distances without assistance 8. When sitting can you bend your knees?  Yes  No If no, which knee is affected?  Right  Left  Both 9. I need assistance in the following areas Eating  Yes  No Washing  Yes  No Showering  Yes  No Dressing  Yes  No Using toilet  Yes  No Transferring  Yes  No Night Assistance  Yes  No Other (Please give details) 10. I have problems with Hearing  Yes  No Sight  Yes  No Speech  Yes  No Incontinence  Yes  No  Sometimes Diabetes  Yes  No Epilepsy  Yes  No Allergies  Yes  No Other (Please give details) 11. I also have the following Heart condition  Yes  No Chest complaint  Yes  No Confusion/Vagueness  Yes  No Infectious disease  Yes  No Other (Please give details) 12.Current treatment. Are you able to take your own medicine?  Yes  No NB: If no please give dosage and frequency 13. How much do you weight?  6 - 10 stone  10 - 15 stone  15 - 20 stone  20 - 25 stone  Over 25 stone 14. Do you use a wheelchair?  All the times  Sometimes  Outdoors only  No Is it manual?  Yes  No Can you propel yourself?  Yes  No  Indoor  Outdoor Is it electrical/scooter  Yes  No Advise weight of wheelchair When travelling on the coach do you wish to  Remain in your chair  Transfer to a seat 15. I will be bringing  Manual wheelchair  Electric wheelchair  Walking aid (specify)  Both  Scooter 16. I require a special diet  No  Yes If yes, please specify