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Are you enquiring on behalf of someone else? *
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Gender
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Interpreter required
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dd/mm/yyyy
or
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Choose the age group
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Already known to Haringey Adult Services?
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Have any difficulty washing or dressing?
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Have any difficulty getting in or out of bed?
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Have any difficulty getting in or out of the bath or shower?
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Have any difficulty getting on or off the toilet?
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Have any difficulty getting in or out of a chair?
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Have any difficulty preparing a meal or carrying a meal from the kitchen?
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Manage to get out of the house?
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Receive help from anyone at the moment?
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Have any difficulties with mobility as a result of visual impairment?
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e.g. when working, studying or shopping
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Have any difficulties living independently as a result of visual impairment?
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e.g. with cooking, food preparation, personal care, housework or managing medication
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Have any difficulties with communication as a result of visual impairment?
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e.g. using the phone, reading or writing
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Had worsening eyesight in the last 12 months?
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Been registered as blind or partially sighted, or have an eye condition?
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Wear a hearing aid?
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Communicate using British Sign Language?
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Where do you live?
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Who do you live with?
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Is there anything else we can help you with or you think we should know?
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