CHAT Tool - Offender Health Research Network

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Tick No or Yes as appropriate for each question and include additional notes No Yes GENERAL PHYSICAL HEALTH – are there any general symptoms troubling you at the moment Please list: APPETITE – are you eating more or less than usual WEIGHT - have you lost or gained weight recently FATIGUE – have you recently felt more tired than usual FEVER – have you recently felt shivery or hot and cold Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 27 | P age
Tick No or Yes as appropriate for each question and include additional notes No Yes SWEATS – have you recently been feeling sweaty at night or any other time PAIN – have you recently had any pain anywhere MAJOR ILLNESSES – have you ever been seriously ill – What When Outcome Give details: HOSPITAL – have you ever been in hospital – Where Why How long Name of consultant Give details: Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 28 | P age
Page 1 and 2: Comprehensive Health Assessment Too
Page 3 and 4: Mental Health Assessment No Yes Is
Page 5 and 6: CHAT RECEPTION SCREEN • Every you
Page 7 and 8: Medical and Psychiatric History Doc
Page 9 and 10: 5. Do you have DIABETES MELLITUS If
Page 11 and 12: Reception Screen Section Two: Subst
Page 13 and 14: 6. Is the young person withdrawing
Page 15 and 16: Tick No or Yes as appropriate for e
Page 19 and 20: Documents you have access to at the
Page 21 and 22: CHAT Immediate Care Plan Name: DOB:
Page 23 and 24: Substance Misuse Service No Yes No
Page 25 and 26: Is the young person subject to a CH
Page 27: MMR BCG HPV Hep A Hep B Typhoid Flu
Page 43 and 44: Disability and Impairment Invitatio
Page 45 and 46: Physical Health Summary/Review Summ
Page 47 and 48: Do the accompanying documents or in
Page 49 and 50: Drug/Alcohol History and Misuse (Co
Page 51 and 52: Drug/Alcohol History and Misuse (Co
Page 53 and 54: Withdrawal - These symptoms are der
Page 55 and 56: DRUG/ALCOHOL USE Where do you usual
Page 57 and 58: Employment E.g. lack of qualificati
Page 59 and 60: Risk Review Tick No or Yes as appro
Page 61 and 62: CHAT MENTAL HEALTH ASSESSMENT • E
Page 79 and 80:
Tick No or Yes as appropriate for e
Page 81 and 82:
Risk Review Tick No or Yes as appro
Page 83 and 84:
CHAT NEURODISABILITY ASSESSMENT •
Page 85 and 86:
Tick No or Yes as appropriate for e
Page 87 and 88:
After a head injury or accident som
Page 89 and 90:
NARRATIVE TASK Ask the young person
Page 91 and 92:
Learning Disability and Educational
Page 93 and 94:
INFORMATION FROM THE YOUNG PERSON T
Page 95 and 96:
Autistic Spectrum Disorder Start by
Page 97 and 98:
Section 3: In social interactions d
Page 99 and 100:
Risk Review Tick No or Yes as appro
Page 101 and 102:
Name: CHAT CARE PLAN DOB: Date: NHS
Page 103 and 104:
Problem/Issue Intervention/Action R
Page 105 and 106:
Initial Weight: Date: Discharge Wei
Page 107 and 108:
Summary of any current or previous
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CHAT Tool - Offender Health Research Network

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