Alone With spouse, partner With family In residential accommodation Other: please specify: ___________________________________ Prefer not to say you have any long-standing physical or mental illness, or disability? By long-standing I mean anything that has troubled you over a period of at least 12 months or that is likely to affect you over a period of at least 12 months. Yes No Prefer not to say there anyone who is sick, disabled or elderly whom you look after or give special help to (for example, a sick, disabled or elderly relative, wife, husband, partner, child or friend)? Yes No Prefer not to say
Alone With spouse, partner With family In residential accommodation Other: please specify: ___________________________________ Prefer not to say you have any long-standing physical or mental illness, or disability? By long-standing I mean anything that has troubled you over a period of at least 12 months or that is likely to affect you over a period of at least 12 months. Yes No Prefer not to say there anyone who is sick, disabled or elderly whom you look after or give special help to (for example, a sick, disabled or elderly relative, wife, husband, partner, child or friend)? Yes No Prefer not to say
cmf_toolkit_3.3_large_print.docx