1. According to our records, you have in the past received Carer’s Allowance. Are you currently receiving Carer’s Allowance either just yourself or jointly with your spouse or partner?

2. Last amount received?

3. What period does this cover?

1. Asthma
2. Arthritis
3. Congestive heart failure
4. Coronary heart disease
5. Angina
6. Heart attack or myocardial infarction
7. Stroke
8. Emphysema
11. Chronic bronchitis
21. COPD (Chronic Obstructive Pulmonary Disease)
10. Hypothyroidism or an under-active thyroid
12. Any kind of liver condition
13. Cancer or malignancy
14. Diabetes
15. Epilepsy
16. High blood pressure/hypertension
22. An emotional, nervous or psychiatric problem.
19. Multiple Sclerosis
20. H.I.V.
18. Other long standing/chronic condition
96. None of these