NHS Continuing Healthcare
Checklist
July 2022
Published May 2022
NHS Continuing Healthcare Checklist (July 2022)
2
What is the Checklist and why is it used?
1. The Checklist is a screening tool which can be used in a variety of settings to help
practitioners identify individuals who may need a referral for a full assessment of eligibility
for NHS Continuing Healthcare.
2. All staff who complete the Checklist should be familiar with the principles of the National
Framework for Continuing Healthcare and NHS-funded Nursing Care and also be familiar
with the Decision Support Tool for NHS Continuing Healthcare.
3. The Checklist threshold at this stage of the process has intentionally been set low, in order
to ensure that all those who require a full assessment of eligibility for NHS Continuing
Healthcare have this opportunity. Practitioners should advise those for whom the Checklist
is completed that a positive checklist does not automatically lead to eligibility for CHC, and
only indicates that the individual requires a full assessment for NHS Continuing Healthcare.
4. There are two potential outcomes following completion of the Checklist:
• a negative Checklist, meaning the individual does not require a full assessment of
eligibility and they are not eligible for NHS Continuing Healthcare; or
• a positive Checklist meaning an individual now requires a full assessment of
eligibility for NHS Continuing Healthcare. It does not necessarily mean the individual
is eligible for NHS Continuing Healthcare.
Note:
All these tools are available electronically (as Word documents) and pages or boxes can be
expanded as necessary.
It is important to note that these are national tools and the content should not be changed,
added to or abbreviated in any way. However, ICBs may attach their logo and additional patient
identification details if necessary (e.g. adding NHS number, etc.).
NHS Continuing Healthcare Checklist (July 2022)
3
When should the Checklist be completed?
5. Where there may be need for NHS Continuing Healthcare, the Checklist should normally be
completed.
6. There will be many situations where it is not necessary to complete the Checklist. See
paragraph 121 of the National Framework and page 9 below.
7. Screening and assessment of eligibility for NHS Continuing Healthcare should be at the
right time and location for the individual and when the individual’s ongoing needs are
clearer. This may be in a variety of settings, although the full assessment of eligibility should
normally take place when the individual is in a community setting, preferably their own
home. The core underlying principle is that individuals should be supported to access and
follow the process that is most suitable for their current and ongoing needs. This will help
practitioners to correctly identify individuals who require a full assessment of eligibility for
NHS Continuing Healthcare.
8. To understand how NHS Continuing Healthcare interacts with hospital discharge, please
refer to paragraphs 101-108 of the National Framework.
Who can complete the Checklist?
9. The Checklist can be completed by a variety of health and social care practitioners, so as
long as they have been trained in its use.
What is the role of the individual in the screening process?
10. The individual should be given reasonable notice of the intention to undertake the Checklist
and have the process explained to them. They should normally be given the opportunity to
participate actively in the completion of the Checklist, together with any representative they
may have, so that they can contribute their views about their needs.
11. There are a number of principles which underpin the NHS Continuing Healthcare process:
most importantly that assessments and reviews should always focus on the individual's
needs and follow a person-centred approach. The individual should be fully informed and
empowered to participate actively in the assessment process and any subsequent reviews,
and their views should be considered. In addition, there are a number of legal requirements
when it comes to an individual's consent for parts of the NHS Continuing Healthcare
process.
12. In the spirit of the person-centred approach, practitioners should make all reasonable efforts
to seek the participation of the individual (or their representative) for the assessment and
review process for NHS Continuing Healthcare, during each stage of the process. For a
NHS Continuing Healthcare Checklist (July 2022)
4
comprehensive assessment, the best evidence available at the relevant time should be
considered. This should involve consideration of the individual's (or their representative's)
view, and they should be empowered and assisted to participate. Throughout the process,
this person-centred approach should be embedded in all decisions which relate to the
individual's needs assessment, and their care planning.
13. Consent is a legal requirement for any physical intervention on, or examination of, a person
with capacity to give consent. To the extent that screening for NHS Continuing Healthcare
involves such an intervention or examination, informed consent must be sought from an
individual with capacity to give consent. Please refer to paragraph 85 of the National
Framework which gives detailed guidance on what is required for consent to be valid.
14. It is necessary to obtain an individual's explicit consent before sharing any personal data
with a third party such as a family member, friend, advocate, and/or other representative.
15. However, it is not necessary to seek consent from an individual in order to share their
personal data as part of their NHS Continuing Healthcare assessment (and subsequent
reviews) between health and social care professionals.
16. If there is a concern that the individual may not have capacity to give consent to a physical
intervention/examination that is part of the assessment process, or to the sharing of
personal data with third parties such as a family member, friend, advocate, and/or other
representative, this should be determined in accordance with the Mental Capacity Act 2005
and the associated code of practice. It may be necessary for a 'best interests' decision to be
made, bearing in mind the expectation that everyone who is potentially eligible for NHS
Continuing Healthcare should have the opportunity to be considered for eligibility. Guidance
on the application of the Mental Capacity Act 2005 in such situations is provided in
paragraphs 86-96 of the National Framework.
How should the Checklist be completed?
17. Completion of the Checklist is intended to be relatively quick and straightforward. It is not
necessary to provide additional detailed evidence along with the completed Checklist.
18. Practitioners should compare the domain descriptors to the needs of the individual and
select level A, B or C, as appropriate, choosing whichever most closely matches the
individual. If the needs of the individual are the same or greater than anything in the A
column, then ‘A’ should be selected. Practitioners should briefly summarise the individual’s
needs which support the level chosen, recording references to evidence as appropriate.
19. A full assessment for NHS Continuing Healthcare is required if there are:
• two or more domains selected in column A;
• five or more domains selected in column B, or one selected in A and four in B; or
NHS Continuing Healthcare Checklist (July 2022)
5
• one domain selected in column A in one of the boxes marked with an asterisk (i.e.
those domains that carry a priority level in the Decision Support Tool), with any
number of selections in the other two columns.
20. There may very occasionally be circumstances where a full assessment of eligibility for NHS
Continuing Healthcare is appropriate even though the individual does not apparently meet
the indicated threshold as set out above. A clear rationale must be given in such
circumstances and local protocols followed.
21. The principles in relation to ‘well-managed need’ (outlined in the Assessment of Eligibility
section of the National Framework, paragraphs 162-166) apply equally to the completion of
the Checklist as they do to the Decision Support Tool.
What happens after the Checklist?
22. Whatever the outcome of the Checklist – whether or not a referral for a full assessment of
eligibility for NHS Continuing Healthcare is considered necessary – the outcome must be
communicated clearly and in writing to the individual or their representative, as soon as is
reasonably practicable. This should include the reasons why the Checklist outcome was
reached. Normally this will be achieved by providing a copy of the Checklist.
What happens following a negative Checklist?
23. A negative Checklist means the individual does not require a full assessment of eligibility
and they are not eligible for NHS Continuing Healthcare.
24. Where it can reasonably be anticipated that the individual’s needs are likely to increase in
the next three months (e.g. because of an expected deterioration in their condition), this
should be recorded and a decision made as to whether the checklist should be reviewed
within a specified period of time.
25. If an individual has been screened out following completion of the Checklist, they may ask
the ICB to reconsider the Checklist outcome. The ICB should give this request due
consideration, taking account all of the information available, and/or including additional
information from the individual or carer, though there is no obligation for the ICB to
undertake a further Checklist.
What happens following a positive Checklist?
26. A positive Checklist means that the individual requires a full assessment of eligibility for
NHS Continuing Healthcare. It does not necessarily mean that the individual will be found
eligible for NHS Continuing Healthcare (refer to paragraphs 134-137 of the National
Framework).
NHS Continuing Healthcare Checklist (July 2022)
6
27. An individual should not be left without appropriate support while they await the outcome of
the assessment and decision-making process.
NHS Continuing Healthcare Checklist (July 2022)
7
NHS Continuing Healthcare Needs Checklist
Date of completion of Checklist _____________________________
Name D.O.B. DOB
NHS number and GP/Practice:
Permanent address and telephone number
Current location (if different from
permanent address)
Gender _____________________________
Please ensure that the equality monitoring form at the end of the Checklist is completed
Was the individual involved in the completion of the Checklist? Yes/No (please delete as
appropriate)
Was the individual offered the opportunity to have a representative such as a family member or
other advocate present when the Checklist was completed? Yes/No (please delete as
appropriate)
If yes, did the representative attend the completion of the Checklist? Yes/No (please delete as
appropriate)
Please give the contact details of the representative (name, address and telephone
number).
Did you explain to the individual how their personal data will be shared with the different
organisations involved in their care? Yes/No (please delete as appropriate)
Continued overleaf
NHS Continuing Healthcare Checklist (July 2022)
8
Did you explain to the individual how their personal data will be shared with other third parties,
such as a family member, friend, advocate and/or other representative? This consent should be
recorded in writing, and ideally identify the individuals with whom the data can be shared (e.g.
on the Consent form). Yes/No (please delete as appropriate)
NHS Continuing Healthcare Checklist (July 2022)
9
When not to screen
There will be many situations where it is not necessary to complete the Checklist.
Practitioners should review the statements below on when it may not be appropriate to screen for NHS Continuing Healthcare before they
start the process of completing the Checklist.
The situations where it is not necessary to complete the Checklist include:
(a) It is clear to practitioners working in the health and care system that there is no need for NHS Continuing Healthcare at this point in
time. Where appropriate/relevant this decision and its reasons should be recorded. If there is doubt between practitioners, the Checklist
should be undertaken.
(b) The individual has short-term health care needs or is recovering from a temporary condition and has not yet reached their optimum
potential (although if there is doubt between practitioners about the short-term nature of the needs it may be necessary to complete the
Checklist). See paragraphs 101-108 of the National Framework for how NHS Continuing Healthcare may interact with hospital
discharge.
(c) It has been agreed by the ICB that the individual should be referred directly for full assessment of eligibility for NHS Continuing
Healthcare.
(d) The individual has a rapidly deteriorating condition and may be entering a terminal phase – in these situations the Fast Track Pathway
Tool should be used instead of the Checklist.
(e) An individual is receiving services under Section 117 of the Mental Health Act that are meeting all of their assessed needs.
(f) It has previously been decided that the individual is not eligible for NHS Continuing Healthcare and it is clear that there has been no
change in needs.
If upon review of these statements, it is deemed that it is not necessary to screen for NHS Continuing Healthcare at this time, the
decision not to complete the Checklist and its reasons should be clearly recorded in the patient’s notes.
NHS Continuing Healthcare Checklist (July 2022)
10
Name of individual
Date of completion
C
B
A
Breathing*
Normal breathing, no issues with
shortness of breath.
OR
Shortness of breath or a condition,
which may require the use of inhalers
or a nebuliser and has no impact on
daily living activities.
OR
Episodes of breathlessness that
readily respond to management and
have no impact on daily living
activities.
Shortness of breath or a condition, which may
require the use of inhalers or a nebuliser and
limit some daily living activities.
OR
Episodes of breathlessness that do not
consistently respond to management and
limit some daily activities.
OR
Requires any of the following:
- low level oxygen therapy (24%);
- room air ventilators via a facial or nasal
mask;
- other therapeutic appliances to maintain
airflow where individual can still
spontaneously breathe e.g. CPAP
(Continuous Positive Airways Pressure) to
manage obstructive apnoea during sleep.
Is able to breathe independently
through a tracheotomy that they can
manage themselves, or with the
support of carers or care workers.
OR
Breathlessness due to a condition
which is not responding to
therapeutic treatment and limits all
daily living activities.
OR
A condition that requires
management by a non-invasive
device to both stimulate and
maintain breathing (non-invasive
positive airway pressure, or non-
invasive ventilation)
Brief
description
of need and
source
of evidence
to support
the chosen
level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
11
Name of individual
Date of completion
C
B
A
Nutrition –
Food and
Drink
Able to take adequate food and drink
by mouth to meet all nutritional
requirements.
OR
Needs supervision, prompting with
meals, or may need feeding and/or a
special diet (for example to manage
food intolerances/allergies).
OR
Able to take food and drink by mouth
but requires additional/supplementary
feeding.
Needs feeding to ensure adequate intake of
food and takes a long time (half an hour or
more), including liquidised feed.
OR
Unable to take any food and drink by mouth,
but all nutritional requirements are being
adequately maintained by artificial means,
for example via a non-problematic PEG.
Dysphagia requiring skilled
intervention to ensure adequate
nutrition/hydration and minimise the
risk of choking and aspiration to
maintain airway.
OR
Subcutaneous fluids that are
managed by the individual or
specifically trained carers or care
workers.
OR
Nutritional status ‘at risk’ and may
be associated with unintended,
significant weight loss.
OR
Significant weight loss or gain due
to an identified eating disorder.
OR
Problems relating to a feeding
device (e.g. PEG) that require
skilled assessment and review.
Brief
description of
need and
source
of evidence
to support the
chosen level
Write A, B or C
below:
NHS Continuing Healthcare Checklist (July 2022)
12
Name of individual
Date of completion
C
B
A
Continence
Continent of urine and faeces.
OR
Continence care is routine on a day-to-day
basis.
OR
Incontinence of urine managed through,
for example, medication, regular toileting,
use of penile sheaths, etc.
AND
Is able to maintain full control over bowel
movements or has a stable stoma, or may
have occasional faecal
incontinence/constipation.
Continence care is routine but requires
monitoring to minimise risks, for
example those associated with urinary
catheters, double incontinence, chronic
urinary tract infections and/or the
management of constipation or other
bowel problems.
Continence care is problematic and
requires timely and skilled
intervention, beyond routine care.
(for example frequent bladder
wash outs/irrigation, manual
evacuations, frequent re-
catheterisation).
Brief
description of
need and
source
of evidence to
support the
chosen level
Write A, B or C
below:
NHS Continuing Healthcare Checklist (July 2022)
13
Name of individual
Date of completion
C
B
A
Skin and tissue
viability
No risk of pressure damage or skin
condition.
OR
Risk of skin breakdown which requires
preventative intervention once a day or
less than daily, without which skin
integrity would break down.
OR
Evidence of pressure damage and/or
pressure ulcer(s) either with
‘discolouration of intact skin’ or a minor
wound.
OR
A skin condition that requires monitoring
or reassessment less than daily and that
is responding to treatment or does not
currently require treatment.
Risk of skin breakdown which requires
preventative intervention several times
each day, without which skin integrity
would break down.
OR
Pressure damage or open wound(s),
pressure ulcer(s) with ‘partial thickness
skin loss involving epidermis and/or
dermis’, which is responding to
treatment.
OR
An identified skin condition that
requires a minimum of daily treatment,
or daily monitoring/reassessment to
ensure that it is responding to
treatment
Pressure damage or open wound(s),
pressure ulcer(s) with ‘partial
thickness skin loss involving
epidermis and/or dermis’, which is not
responding to treatment.
OR
Pressure damage or open wound(s),
pressure ulcer(s) with ‘full thickness
skin loss involving damage or
necrosis to subcutaneous tissue, but
not extending to underlying bone,
tendon or joint capsule’, which is
responding to treatment.
OR
Specialist dressing regime in place
which is responding to treatment.
Brief description
of need and
source
of evidence to
support the
chosen level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
14
Name of individual
Date of completion
C
B
A
Mobility
Independently mobile.
OR
Able to weight bear but needs
some assistance and/or requires
mobility equipment for daily living.
Not able to consistently weight bear.
OR
Completely unable to weight bear but is
able to assist or cooperate with transfers
and/or repositioning.
OR
In one position (bed or chair) for majority
of the time but is able to cooperate and
assist carers or care workers.
OR
At moderate risk of falls (as evidenced in
a falls history or risk assessment)
Completely unable to weight bear and is
unable to assist or cooperate with
transfers and/or repositioning.
OR
Due to risk of physical harm or loss of
muscle tone or pain on movement needs
careful positioning and is unable to
cooperate.
OR
At a high risk of falls (as evidenced in a
falls history and risk assessment).
OR
Involuntary spasms or contractures
placing the individual or others at risk.
Brief
description of
need and
source
of evidence to
support the
chosen level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
15
Name of individual
Date of completion
C
B
A
Communication
Able to communicate clearly, verbally
or non-verbally. Has a good
understanding of their primary
language. May require translation if
English is not their first language.
OR
Needs assistance to communicate
their needs. Special effort may be
needed to ensure accurate
interpretation of needs or additional
support may be needed either
visually, through touch or with
hearing.
Communication about needs is difficult
to understand or interpret or the
individual is sometimes unable to
reliably communicate, even when
assisted. Carers or care workers may
be able to anticipate needs through
non-verbal signs due to familiarity with
the individual.
Unable to reliably communicate their
needs at any time and in any way, even
when all practicable steps to assist them
have been taken. The individual has to
have most of their needs anticipated
because of their inability to
communicate them.
Brief description
of need and
source
of evidence to
support the
chosen level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
16
Name of individual
Date of completion
C
B
A
Psychological
and emotional
needs
Psychological and emotional needs
are not having an impact on their
health and well-being.
OR
Mood disturbance or anxiety
symptoms or periods of distress, which
are having an impact on their health
and/or well-being but respond to
prompts, distraction and/or
reassurance.
OR
Requires prompts to motivate self
towards activity and to engage them in
care planning, support and/or daily
activities.
Mood disturbance, hallucinations or
anxiety symptoms or periods of
distress which do not readily respond
to prompts, distraction and/or
reassurance and have an increasing
impact on the individual’s health and/or
well-being.
OR
Due to their psychological or emotional
state the individual has withdrawn from
most attempts to engage them in
support, care planning and/or daily
activities.
Mood disturbance, hallucinations or
anxiety symptoms or periods of distress
that have a severe impact on the
individual’s health and/or well-being.
OR
Due to their psychological or emotional
state the individual has withdrawn from
any attempts to engage them in care
planning, support and/or daily activities.
Brief description
of need and
source
of evidence to
support the
chosen level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
17
Name of individual
Date of completion
C
B
A
Cognition
No evidence of impairment,
confusion or disorientation.
OR
Cognitive impairment which requires
some supervision, prompting or
assistance with more complex
activities of daily living, such as
finance and medication, but
awareness of basic risks that affect
their safety is evident.
OR
Occasional difficulty with memory
and decisions/choices requiring
support, prompting or assistance.
However, the individual has insight
into their impairment.
Cognitive impairment (which may
include some memory issues) that
requires some supervision, prompting
and/or assistance with basic care
needs and daily living activities. Some
awareness of needs and basic risks is
evident.
The individual is usually able to make
choices appropriate to needs with
assistance. However, the individual
has limited ability even with
supervision, prompting or assistance to
make decisions about some aspects of
their lives, which consequently puts
them at some risk of harm, neglect or
health deterioration.
Cognitive impairment that could for
example include frequent short-term
memory issues and maybe disorientation
to time and place. The individual has
awareness of only a limited range of
needs and basic risks. Although they
may be able to make some choices
appropriate to need on a limited range of
issues, they are unable to do so on most
issues, even with supervision, prompting
or assistance.
The individual finds it difficult, even with
supervision, prompting or assistance, to
make decisions about key aspects of
their lives, which consequently puts them
at high risk of harm, neglect or health
deterioration.
Brief
description of
need and
source
of evidence to
support the
chosen level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
18
Name of individual
Date of completion
C
B
A
Behaviour*
No evidence of ‘challenging’
behaviour.
OR
Some incidents of ‘challenging’
behaviour. A risk assessment
indicates that the behaviour does
not pose a risk to self, others or
property or create a barrier to
intervention. The individual is
compliant with all aspects of their
care.
‘Challenging’ behaviour that follows a
predictable pattern. The risk
assessment indicates a pattern of
behaviour that can be managed by
skilled carers or care workers who are
able to maintain a level of behaviour
that does not pose a risk to self, others
or property. The individual is nearly
always compliant with care.
‘Challenging’ behaviour of type and/or
frequency that poses a predictable risk to
self, others or property. The risk
assessment indicates that planned
interventions are effective in minimising
but not always eliminating risks.
Compliance is variable but usually
responsive to planned interventions.
Brief
description of
need and
source
of evidence to
support the
chosen level
Write A, B or
C below:
NHS Continuing Healthcare Checklist (July 2022)
19
Name of individual
Date of completion
C
B
A
Drug therapies
etc.*
Symptoms are managed effectively
and without any problems, and
medication is not resulting in any
unmanageable side-effects.
OR
Requires supervision/administration
of and/or prompting with medication
but shows compliance with
medication regime.
OR
Mild pain that is predictable and/or
is associated with certain activities
of daily living; pain and other
symptoms do not have an impact on
the provision of care.
Requires the administration of
medication (by a registered nurse,
carer or care worker) due to:
– non-compliance, or
– type of medication (for example
insulin); or
– route of medication (for example
PEG).
OR
Moderate pain which follows a
predictable pattern; or other symptoms
which are having a moderate effect on
other domains or on the provision of
care.
Requires administration and monitoring of
medication regime by a registered nurse,
carer or care worker specifically trained
for this task because there are risks
associated with the potential fluctuation of
the medical condition or mental state, or
risks regarding the effectiveness of the
medication or the potential nature or
severity of side-effects. However, with
such monitoring the condition is usually
non-problematic to manage.
OR
Moderate pain or other symptoms which
is/are having a significant effect on other
domains or on the provision of care.
Brief
description of
need and
source
of evidence to
support the
chosen level
Write A, B or C
below:
NHS Continuing Healthcare Checklist (July 2022)
20
Name of individual
Date of completion
C
B
A
Altered states of
consciousness*
No evidence of altered states of
consciousness (ASC).
OR
History of ASC but effectively
managed and there is a low risk of
harm.
Occasional (monthly or less frequently)
episodes of ASC that require the
supervision of a carer or care worker to
minimise the risk of harm.
Frequent episodes of ASC that require
the supervision of a carer or care
worker to minimise the risk of harm.
OR
Occasional ASCs that require skilled
intervention to reduce the risk of harm.
Brief description
of need and
source
of evidence to
support the
chosen level
Write A, B or C
below:
Total from all
pages
NHS Continuing Healthcare Checklist (July 2022)
21
Please highlight the outcome indicated by the Checklist:
1. Referral for full assessment for NHS Continuing Healthcare is necessary (known as a
positive Checklist).
Or
2. No referral for full assessment for NHS Continuing Healthcare is necessary (known as a
negative Checklist).
Rationale for decision
Please send this completed Checklist to the ICB without delay.
Name(s) and signature(s) of assessor(s) Date
Contact details of assessors (name, role, organisation, telephone number, email address)
NHS Continuing Healthcare Checklist (July 2022)
22
About you — equality monitoring
We collect equalities information to meet our duties under the Equality Act 2010 and develop
our insights into CHC patients and ensure we provide appropriate care. The categories included
in the questions may not be exhaustive or reflect how you feel or identify. We will be reviewing
these to align with approaches across Government. Filling these in is optional, and you do not
have to provide an answer if you do not wish to do so.
Please provide us with some information about yourself. We collect information to help us
understand whether people are receiving fair and equal access to NHS Continuing Healthcare
(CHC) via the NHS CHC Patient Level Data Set (PLDS) which is used to help achieve better
patient outcomes, better experiences and better use of resources in CHC. The lawful basis for
collecting this information is Article 6 (1) (c) of the GDPR enacted by the Data Protection Act
2018. Please note that NHS CHC PLDS data is pseudonymised for analysis purposes. This
means that identifiers such as names, NHS numbers and dates of birth are removed. Detailed
information about the use of individual’s identifiable data is publicly available at
https://digital.nhs.uk/about-nhs-digital/our-work/keeping-patient-data-safe/gdpr/gdpr-register
1 What is your gender?
Tick one box only
☐ Male
☐ Female
☐ Indeterminate (unable to be classified as
either male or female)
☐ I prefer not to answer
2 Which age group applies to you?
Tick one box only
☐ 18-24
☐ 25-34
☐ 35-44
☐ 45-54
☐ 55-64
☐ 65-74
☐ 75-84
☐ 85+
☐ I prefer not to answer
3 Do you have a disability as defined by
the Equalities Act 2010?
Tick one box only.
The Equality Act 2010 defines a person with
a disability as someone who has a physical
or mental impairment that has a substantial
and long-term adverse effect on his or her
ability to carry out normal day to day
activities.
☐ No
☐ Yes
☐ I prefer not to answer
4 What is your ethnic group?
Tick one box only.
A White
☐ British
☐ Irish
☐ Any other White background, write below
Click here to enter text.
B Mixed
☐ White and Black Caribbean
☐ White and Black African
☐ White and Asian
☐ Any other Mixed background, write below
Click here to enter text.
C Asian or Asian British
☐ Indian
☐ Pakistani
NHS Continuing Healthcare Checklist (July 2022)
23
☐ Bangladeshi
☐ Any other Asian background, write below
Click here to enter text.
D Black, or Black British
☐ African
☐ Caribbean
☐ Any other Black background, write below
Click here to enter text.
E Other ethnic group
☐ Chinese
☐ Any other ethnic group, write below
Click here to enter text.
Prefer not to say
☐ I prefer not to answer
5 What is your religious or other belief
system affiliation?
Tick one box only
☐ Baha'i
☐ Buddhist
☐ Christian
☐ Hindu
☐ Jewish
☐ Muslim
☐ Pagan
☐ Sikh
☐ Zoroastrian
☐ Other
☐ None
☐ Prefer not to answer
☐ Unknown
6 Which of the following best describes
your sexual orientation?
Tick one box only
☐ Heterosexual or Straight
☐ Gay or Lesbian
☐ Bisexual
☐ Other sexual orientation
☐ Prefer not to answer
Other, write below
Click here to enter text.
24
© Crown copyright 2022
www.gov.uk/dhsc
This publication is licensed under the terms of the Open Government Licence v3.0 except
where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-
government-licence/version/3
Where we have identified any third party copyright information you will need to obtain
permission from the copyright holders concerned.
