PATIENT INFORMATION
Name	Click or tap here to enter text.	CHI Number	Click or tap here to enter text.
Current Place of Care	Choose an Item	Phase of Illness	Choose an item.
Diagnosis	Click or tap here to enter text.
Reason for ongoing support	Choose an item.	Working weight	Click or tap here to enter text.

MEDICATION SUMMARY
Previous Medications: (Last MDT)	Click or tap here to enter text.	Current Medications:	Click or tap here to enter text.
Allergies	Click or tap here to enter text.
Just in case medications	Are all SMP medications PO/SC available in the home?	Choose an item.
If no which medications PO/SC are currently not available in the home?	Click or tap here to enter text.

CLINICAL UPDATE

KEY QUESTIONS AND POINTS FOR DISCUSSION
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Form completed by	Click or tap here to enter text.	Presenting clinician	Click or tap here to enter text.

LOCAL SERVICE PROVISION
Local medical/nursing provision (in hours)	Click or tap here to enter text.	Local medical/nursing provision (out of hours)	Click or tap here to enter text.

THE FOLLOWING SECTIONS WILL BE COMPLETED BY THE CAS TEAM DURING THE MDT

CLINICAL ADVISORY SERVICE MULTI-DISCIPLINARY TEAM MEETING DISCUSSION & FOLLOW UP
Date of MDT	Click or tap to enter a date.	Previously presented to MDT	Choose an item.
MDT Decision	Choose an item.	Bring back to next CAS MDT?	Choose an item.
Recommendations	Click or tap here to enter text.
MDT Chair	Choose an item.
CAS Clinicians present at MDT (initials)	Click or tap here to enter text.
IF REFERRING TEAM HAS ANY QUESTIONS OR QUERIES, THEY SHOULD CONTACT THE SPECIALIST PALLIATIVE CARE TEAM WHICH THE CHILD IS KNOWN TO