HAVE YOU LEFT THE COOKER ON?

Please answer questions below to send the referral form to your local authority. The local authority will contact you within 2 to 5 days to make an appointment.

Have you left the cooker on by mistake?
Yes No
Would you like to be reminded to switch off your cooker?
Yes No
Do you have any difficulties using the oven or cooker controls?
Yes No
Do you have any difficulties seeing the cooker controls?
Yes No
Do you cook whilst in a wheelchair?
Yes No
Do you use the cooker frequently?
Yes No
Do you receive any homecare?
Yes No
Are you seeing an Occupational Therapist or Another Service?
Yes No
Are you concerned about any other risks?
Yes No