CHAT Tool - Offender Health Research Network

Tick No or Yes as appropriate for each question and include additional notes No Yes
EYES, HEARING and ORAL HEALTH
Do you have any problems with your EYES
– redness; soreness; photophobia; blurred or double vision.
Do you wear glasses/contact lenses to see
If Yes are you short or long sighted
When was your eyesight last tested
Do you have any problems with your EARS or HEARING
– redness, hotness, glue-ear; infections; tinnitus; deafness (note right or left ear or both).
Has your sense of smell changed recently
Do you have any problems with your ORAL HEALTH i.e. teeth or gums
– abnormal dentition; tooth decay; gum soreness or redness; bleeding gums; toothache.
If Yes, please provide details below
Last visit to Dentist:
ACTION FOR CARE PLAN
Surname:
DOB:
Forenames:
NHS Number:
CHAT Tool Secure Estate (Version 3 - June 2013)
34 | P age