GP’s contact name and address:
Our direct dial number is
Textphone users with speech or hearing difficulties call
If you get in touch with us, tell us this reference number
About your patient
Date of birth
Your patient is being assessed for Employment and Support Allowance and we need to find out whether they are able
to do any work. By completing this form you will help our medical staff decide whether your patient needs a face-to-
face medical assessment.
NHS doctors have a contractual obligation
to provide the information requested without charge.
The form should be completed from your medical records. A separate examination is not necessary.
It is acceptable for you to delegate completion of the form to your practice nurse, but you must confirm your
authorisation by signing at the end.
Your patient has given consent to allow us to approach you for this information, in accordance with GMC guidelines.
An online version of this report which can be completed electronically and printed is available atwww.dwp.gov.uk/healthcare-professional/guidance
A well completed form may mean that your patient will not need a further medical assessment and will help
us to make a fair decision on benefit entitlement.
You can send us a computer printout of the appropriate part of the patient record if you wish, but you will still have to
complete any sections of the form where the answer is not clear from the printout. We are only able to accept
information directly relevant to our enquiries. If a printout is available, please make sure it includes the following●
Current medication with last prescribed date
Details of the last three consultations. Please remove any third party data.
If you have any queries about this form please phone the number above.
If you would like to discuss anything with our medical staff, please phone the number above and ask for a member of
the medical staff on the customer service desk.
If there is any medical evidence that you think would be harmful to your patient's health, please give us this information
on a separate sheet of paper so that this can be withheld.
Please reply within 5 working days.
A business reply envelope is enclosed for your use.
Thank you for your help.
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Please complete both
sides of this form,
then send it back to us in the envelope we
have sent you. Make sure the address
below shows in the window of the envelope.
Client’s NI number
Office contact name and address:
Client’s date of birth
Please answer the following questions from the information which is currently available to you.
If you need more space for any of your answers, please continue at Part 7
1 When did your patient last see a GP?
2 Current conditions affecting ability to work
Please give us details of those conditions which may have a significant effect on the person’s
capacity to work
Relevant symptoms and signs, including side effects of medication, with dates. For mental health
conditions, please provide brief mental state examination findings, if available.
Past, present and planned investigations and management, including medication, where relevant
If you are sending a computerised printout of current medication you do not need to list this here.
Symptoms and signs
Investigations and management,
date of diagnosis
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3 Current conditions not affecting ability to work
any other relevant conditions that do not affect the ability to work.
4 If known from your knowledge of the patient
, please tick the boxes that apply and
provide a brief explanation if your patient has difficulties with any of the following activities:
Walking or moving
Transferring between seats
Picking up objects
Communicating with others
Learning simple tasks
Awareness of hazards
Initiating and completing
Coping with changes or social
Appropriateness of behaviour
Eating or drinking
5 Does the patient have a
history of threatening or
Tell us about their behaviour within the last 5 years, and whether
they have been identified by the Zero Tolerance (Violent Behaviour)
Initiative. Use the space below at Part 7
6 Could your patient travel to
Please tell us why at Part 7
an examination centre by
public transport or taxi?
7 Additional information
Please continue on a separate sheet if necessary.
The information you have given us may be copied to the patient, their legal representative or the Tribunals Service.
IN CAPITALS Dr
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