NHS Continuing Healthcare

NHS Continuing Healthcare Questionnaire In association with

Questionnaire 1. Full name of patient 2. Home address (prior to transfer into care home if applicable) 3. Patient s Date of Birth 4. Patient s Place of Birth 5. Patient s Surname at birth 6. Patient s NHS Number 7. Name of Patient s General Practitioner Address 8. Name of Patient s Social Worker Address

Section 1 - Medical History 9. Has the patient ever been detained under Section 3 of the Mental Health Act 1983 for treatment? If yes, how long ago or for what reason this occurred. Place X appropriate box 10. Please state the Patient s past and current medical history and physical illnesses in particular whether the Patient has suffered from Diabetes, Epilepsy, Parkinson s Disease, Cancer, Arthritis, Stroke etc (please give dates where possible of diagnosis)

Section 1 - Medical History 11. Name and address of any hospitals attended by the Patient and approximate dates. 12. Is the patient attended by a Specialist nurse (for example Parkinsons, Epilepsy, Diabetic, Community, Psychiatric or Continence nurse), a Dietician, Consultant or other healthcare professional from outside of their home environment? Place X appropriate box If yes, how often are the visits by the above professional (e.g. daily, weekly, fortnightly, monthly etc)?

Section 2 - Care Home Details Please complete this section if the patient is or has been in a residential care setting. If residing in their own home, or currently in hospital, please move to Section 3. 13. Address of current Care Home 14. On what date did the Patient become resident of the above Care Home? 15. Could you please give an estimate of how much has been paid to date to the Care Home(s) to provide care for the Patient? And/or the current weekly or monthly Care Home Fee 16. Please provide any information with relation to previous Care Home(s) where the Patient has resided and exact or approximate dates (if applicable). Care Home Address From To Please give as much detail as possible the more exact the data the better, if you need more space you can include a separate sheet of paper. 17. Please indicate whether the current Care Home is one of the following: A residential home. A nursing home. A residential home for the elderly mentally infirm. A nursing home for the registered elderly mentally infirm. If the care home is a dual registered home, please let us know if the Patient has a residential or nursing bed. Place X more than one if appropriate

Section 3 - Care Needs We need to know whether the Patient needs assistance and supervision on a daily basis to help with activities of daily living. Please can you answer the following questions providing as much information as possible continuing on a separate sheet if required. 18. Personal Care What personal care does the Patient require? (i.e. assistance with washing, bathing, brushing teeth/dentures, dressing/undressing, hair care, nail care) 19. Eating and drinking What assistance does the Patient need with eating or drinking? Can they eat independently or require supervision, reminding, coaching or encouragement? Please tick all of the below statements that apply to the patient: They refuse food They require their food cutting up They require a plate guard They use adapted cutlery The require thickeded fluids They require mashed up/soft foods They require liquidized food The have got a PEG feeding tube/naso gastric feeding tube They have a fortified diet They require supplement drinks They are under the care of Speech and Language Therapy They are under the care of a dietician They have swallowing difficulties They are losing weight They have choking episodes. If so, how often (please give details below)

20. Mobility Please tick all of the below statements that apply to the patient: They are able to walk independently They walk with a walking stick They walk with a Tripod They walk with a Zimmer frame They use a wheelchair The can bear weight (take weight on their legs either with assistance or without) They can stand alone They use a stand aid They use a hoist Staff assist them when getting in and out of bed The experience falls They are under the falls service They require pressure mats to alert staff to their movements Is there a history of falls, and if so how often? Has the Patient sustained injury as a result of falls and was any medical treatment or hospitalisation required as a result? Do they require additional staff in the home due to attempts to mobilise on their own? 21. Skin Integrity Please tick all of the below statements that apply to the patient: Eczema Psoriasis Dry skin Lesions Oedema Ulcers on the skin Pressure areas

Is the Patient under the care of the Tissue Viability Service/nurse? Do they have dressings regularly done by the nursing home nurse and/or district nurse? Do they have a pressure relieving mattress and/or cushion? 22. Continence Please tick all of the below statements that apply to the patient: They are self-caring/take themselves to the toilet They are incontinent of urine They are incontinent of faeces They wear incontinence pads They suffer regularly from urinary tract infections They suffer from constipation They suffer from loose stools They are under the care of the Continence Service They have a self-retaining catheter in place They are intermittently catheterised 23. Communication Can the Patient speak? Can they communicate effectively? Can they make their needs known? (i.e. can they ask for a drink or to go to the toilet?) Do they speak in a confused manner? Can they communicate non-verbally (i.e. point to things, make gestures) Does the patient have a sight or hearing impediment?

24. Medication Please tick all of the below statements that apply to the patient: They are not prescribed any medication They depend on staff to administer their medication They require medication for pain control They refuse their medication They require regular blood tests Does the patient see their GP regularly and, if so, how often? Do they require regular injections? If so, what for and how often? 25. Psychological wellbeing Does the Patient suffer from any mental health problems (i.e. depression, anxiety, distress)? If they are distressed, how to they indicate distress and how often? Do they hallucinate and, if so, how often? Do the hallucinations cause distress? Is the patient often tearful? How do they respond to reassurance? Are they under the care of any local mental health services/practitioners?

26. Cognition Please tick all of the below statements that apply to the patient: They have not got capacity to make simple decisions They are confused They cannot assess risk They do not know where they are They do not know the time of day They do not recognise family They do not know the difference between other residents and staff They do not have any short term memory They do not have any long term memory 27. Behaviour Does the Patient demonstrate any behavioural problems? Do they demonstrate difficult behaviour (i.e. verbal or physical aggression, noisiness, restlessness or disruption)? Do they display disinhibited behaviour (i.e. use of bad language, taking their clothes off inappropriately, making unwanted advances to others)? Does the Patient refuse or resist care or medication? How often does this behaviour occur?

28. Breathing Please tick all of the below statements that apply to the patient: They require inhalers They require medication prescribed for breathing They have recurrent chest infections They are breathless on sitting They are breathless when walking They are prescribed oxygen 29. Altered States of Consciousness Please tick all of the below statements that apply to the patient: They suffer from epilepsy They have fainting attacks They have vacant attacks They have had a stroke They suffer from TIAs They are in a coma They are unresponsiv

Section 4 - Claim Details 30. Have you or anyone else contacted the NHS/Primary Care Trust or Strategic Health Authority about the funding of the patient s care? Place X appropriate box If yes, please provide as much details as you can including the date you first contacted the Health Authority, the date you received a response and details of that response. 31. Is the person completing this questionnaire the Patient? If YES, please sign and date the end of the Form. Place X appropriate box If NO, continue to question 32 and provide us with your contact details. 32. Your Full Name 33. Your Full Address 34. Contact Telephone Number(s) 35. Your Date of Birth 36. Your National Insurance Number 37. Please give details of your relationship to the patient 38. If the Patient cannot complete the Questionnaire themselves please give details as to why.

39. Has the patient appointed you to act on their behalf using an Enduring Power of Attorney or Lasting Power of Attorney, or are you acting as a Receiver/Deputy on the patient s behalf? A. Copy of Enduring Power of Attorney enclosed Copy of Lasting Power of Attorney enclosed Copy of letter of appointment as a Receiver enclosed Copy of Deputyship enclosed B. If we believe that you are eligible to make a claim for NHS Continuing Healthcare Funding, a member of our team will contact you to discuss how the patient can legally appoint you to pursue the claim on their behalf. 40. Does the patient have a current, valid Will in place? It is important that the patient has a Will in place so that if anything happens during the claim, there are executors who can continue with the claim. If we are unable to proceed with this claim having assessed the patient s circumstances, you and they will still qualify for our Free Will writing service and a member of our team will contact you to discuss how our service works.

Declaration I DECLARE THAT THE INFORMATION I HAVE GIVEN IN ANSWER TO ALL THE QUESTIONS IN THIS QUESTIONNAIRE IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. Signed Print name Relationship to client Dated Please return this completed questionnaire to: Farley Dwek Solicitors Limited Suite 1.2, First Floor One Universal Square Devonshire Street rth Manchester M12 6JH If you have any queries, please contact us on: 0161 272 5222 We will assess the information you have provided and contact you to discuss your eligibility for Funding as soon as possible.

Supplementary answers