HealthWhat you tell us about your health

To receive the right support, we need to know if your
health affects you at work or prevents you from
working.

Please answer honestly. We’ll need to check what you tell us about
your health.

HealthDisability, illness and ongoing conditions

Do you have a disability, illness or ongoing condition
that you’d like to tell us about?

Yes
No

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HealthReport health conditions

Tell us about any disabilities, illnesses or ongoing conditions.

Name of condition

Add a condition

(on the government site, you will be able to add multiple conditions)

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HealthAbility to work

Does your condition restrict your ability to work
or look for work?

Yes
No

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HealthDetails on my fit note

Fit note start date

DD MM YYYY

Fit note end date

DD MM YYYY

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HealthAbout your doctor or medical centre

Name of doctor or medical centre

Street

Town

Postcode

Telephone number

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HealthPregnancy

To give you the right support, there are a few more things we need to know about your health.

If you’re pregnant, does your health put you or your unborn child at
risk?

Not applicable

Yes

No

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HealthTerminal illness

Have you been diagnosed with a terminal illness?

Yes
No

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HealthHospital stays

Are you currently in or expecting to go into hospital for more than
24 hours?

This includes residential rehabilitation.

Yes
No

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HealthMedical treatments

Are you recovering from, receiving or expecting to receive any
medical treatments?

Yes
No

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HealthSupport at work

Tell us if you need any special support to help you at work.

I have a wheelchair

I need a hearing loop

I have an assistance dog

I need other support (optional).

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HealthWhat you need to do

If your ability to work or look for work is still restricted after the end
date on your fit note, you will need to provide a new one.

If we don’t receive an up-to-date fit note, we will assume that you are
able to work.

If you are unable to work for more than 4 weeks, you will need to
provide more details and may need to attend an assessment.

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HealthUnable to work

From which date have you been unable to work?

DD MM YYYY

If you are ill for more than 7 days and you want to claim, you need a fit
note from your doctor.

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HealthWhat you need to do

If you are unable to work or look for work after seven days, you will
need a fit note from your doctor.

If we don’t receive an up-to-date fit note, we will assume that you are
able to work.

If you are unable to work for more than 4 weeks, you will need to
provide more details and may need to attend an assessment.

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Health

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HealthWhat you tell us about your health

HealthDisability, illness and ongoing conditions

HealthReport health conditions

HealthAbility to work

HealthDetails on my fit note

HealthAbout your doctor or medical centre

HealthSharing your information

HealthPregnancy

HealthTerminal illness

HealthHospital stays

HealthMedical treatments

HealthSupport at work

HealthWhat you need to do

HealthUnable to work

HealthWhat you need to do