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 NERVOUS SYSTEM Does the young person have any ORIENTATION problems - ask date, time, place (remember responses will be age related) Are there problems with MEMORY or recall - ask where the young person lives; return to a question answered before; can they recall your name (remember responses will be age related) Do you get regular HEADACHES - how often; what do the headaches feel like; can the young person point to where they are Do you have an UNSTEADY GAIT - sometimes feel dizzy or unsteady on your feet – how often; what time of day; what are they doing at the time Do you ever have FITS, FAINTS or SEIZURES - describe what happens; duration; frequency and length; time of day; premonition; loss of sphincter control; injuries. ACTION FOR CARE PLAN Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 41 | P age
Disability and Impairment Invitation to Declare Disability or Impairment The youth justice system/Department of Health requires that a declaration of disability and impairment is completed (young people who have a sight or hearing impairment or have difficulties with understanding may need assistance to complete this form). A disabled person is defined as someone who has a physical, sensory or mental impairment which has a substantial and long-term (12 months or more) effect on their ability to carry out normal day-to-day activities. For example, someone who uses a wheelchair or has difficulty in walking, someone who is deaf, someone who has significantly impaired speech or who is blind or partially sighted, someone with epilepsy or someone who has a mental illness, may be classified as having a disability. Also covered by the Act are people who have a severe disfigurement, or any medical condition that might initially have only a slight effect on a person’s ability to carry out normal day-to-day activities, but which might get worse (See the Equality Act 2010 and the relevant guidance which can be found at http://www.equalityhumanrights.com/advice-and-guidance/newequality-act-guidance/index.html) Name: NHS Number: Establishment Number (e.g. Prison) if applicable: Inform the young person that the information on this form will be held in their personal record. The people who will see this form are staff involved with the young person during their time in the establishment. This is so that suitable arrangements may be made for their day to day activities. 1. Do you agree to give information about your needs: Please tick appropriate box: Yes No If no, please go to question 3 to sign the form 2. Please tick any of the following that apply to the young person and include details in the care plan and communicate with relevant staff:- Hearing impairment Visual impairment Speech impairment Reduced mobility Difficulty with physical co-ordination Severe disfigurement Mental health problem Neurodisability e.g. autism, attention deficit hyperactivity disorder Learning difficulties Chronic long term conditions e.g. asthma, diabetes or epilepsy Progressive condition (e.g. cancer, muscular dystrophy) Other (please specify) 4. Young person’s signature: Date: Surname: DOB: Forenames: NHS Number: CHAT Tool Secure Estate (Version 3 - June 2013) 42 | 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 and 28: MMR BCG HPV Hep A Hep B Typhoid Flu
Page 41: Tick No or Yes as appropriate for e
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 81 and 82: Risk Review Tick No or Yes as appro
Page 83 and 84: CHAT NEURODISABILITY ASSESSMENT •
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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