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Care and health self-help tool

  1. Self-help form

Are you having problems living safely and well at home?

Answer these 14 questions to get information about support, equipment and local services which could help you.

You can send the results to your email address or print them off.

To get the best results:

  • choose ‘no’ if you can’t do any part of the question, even if you can do some of the things
  • answer the questions based on how you feel on the days you can’t achieve as much as you would like

doing this will give you more information about services that could help you.

1
I have a disability, or physical or mental illness or problem, which stops me from living my life the way I would like to
I  have a disability, or physical or mental illness or problem, which stops me from living my life the way I would like to
2
I can shop for food, prepare meals, eat a healthy diet and drink plenty of fluids
I can shop for food, prepare meals, eat a healthy diet and drink plenty of fluids
3
I can keep myself clean - brushing my teeth and washing my hair and body
I can keep myself clean - brushing my teeth and washing my hair and body
4
I can go to the toilet unaided
I can go to the toilet unaided
5
I can get dressed and undressed, and keep my clothes clean
I can get dressed and undressed, and keep my clothes clean
6
I can move around my home and my neighbourhood without a walking aid
I can move around my home and my neighbourhood without a walking aid
7
I can keep my home clean and tidy
I can keep my home clean and tidy
8
I feel safe in my home – my home is secure and I feel safe from crime or pressure selling
I feel safe in my home – my home is secure and I feel safe from crime or pressure selling
9
I feel safe from physical or financial abuse - I'm not being hurt and do not feel that I'm being taken advantage of
I feel safe from physical or financial abuse - I'm not being hurt and do not feel that I'm being taken advantage of
10
I can stay in contact with my friends and family – I can maintain relationships through phone calls, visits, social networks or tools such as Skype
I can stay in contact with my friends and family – I can maintain relationships through phone calls, visits, social networks or tools such as Skype
11
I can work, learn or volunteer if I need or want to
I can work, learn or volunteer if I need or want to
12
I can take part in social activities with friends and can use local facilities – such as a library, leisure centre, church, social club or pub
I can take part in social activities with friends and can use local facilities – such as a library, leisure centre, church, social club or pub
13
I can manage looking after a family member who relies on me for care and support
I can manage looking after a family member who relies on me for care and support
14
I can manage my alcohol intake, and do not use alcohol or drugs to help me through the day
I can manage my alcohol intake, and do not use alcohol or drugs to help me through the day

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