NB All are anonymised prior to consultation with the NHS England Violent and Aggressive Patient Liaison Panel Does the Patient have an existing Mental Yes / No Health Condition? If Yes, please provide further details: Medical Conditions Other Health Care Providers Please list any existing Medical Conditions, particularly Please provide the contact where these may have an effect on the patients’ behaviour. details of any Health Care E.g. Their Mental Health Status, any learning disabilities, providers, e.g. Mental Health Drug or Alcohol abuse Team Workers, District Nurses, or Health Visitors and confirm that you will inform them that the patient will be placed on the Violent Patient Scheme subject to approval of the referral request Existing Medication Please list any medication currently being prescribed or any ongoing medication monitoring needs that the patient has e.g. Warfarin or Diabetes monitoring
NB All are anonymised prior to consultation with the NHS England Violent and Aggressive Patient Liaison Panel Does the Patient have an existing Mental Health Condition? Yes / No If Yes, please provide further details: Medical Conditions Other Health Care Providers Please list any existing Medical Conditions, particularly where these may have an effect on the patients’ behaviour. E.g. Their Mental Health Status, any learning disabilities, Drug or Alcohol abuse Please provide the contact details of any Health Care providers, e.g. Mental Health Team Workers, District Nurses, or Health Visitors and confirm that you will inform them that the patient will be placed on the Violent Patient Scheme subject to approval of the referral request Existing Medication Please list any medication currently being prescribed or any ongoing medication monitoring needs that the patient has e.g. Warfarin or Diabetes monitoring
special-allocation-scheme-violence-reporting-form.docx