Date: Today M-D-Y
Patient name:* must provide value
Patient date of birth:* must provide value
Today M-D-Y
Patient current age:
Name of person completing this form:
Relationship to the patient:
Email address of person completing this form:
Does the patient have a guardian? Yes No
Guardian name:
Guardian contact information:
If the guardian is appointed by the court, a copy of the guardianship should be submitted to the hospital or doctor.
1. How does the patient like to communicate needs/wants? Talking
Sign Language
Typed words
Handwritten words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Facial expressions (smiling, frowning, etc.)
Other
(check all that apply)
If other, please explain:
2. What other ways will the patient tell us what he/she needs/wants? Talking
Sign Language
Typed words
Handwritten words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Facial expressions (smiling, frowning, etc.)
Other
(check all that apply)
If other, please explain:
3. How does the patient communicate "yes" or "no" when asked a question?
4. How does the patient learn new information or instructions? Talking
Sign Language
Typed words
Handwritten words
Tablet or communication device
Stories
Pictures or symbols
Pictures with words
To Do/Finished Boards
First/Then Boards
Other
(check all that apply)
If other, please explain:
5. How does the patient know that time is passing? Using a clock or watch
Using a timer
Using schedule boards
Counting aloud
Other
(check all that apply)
If other, please explain:
6. What is the best way for us to prepare the patient for tests? (i.e. how long the wait will be for a test or how long the test will take)?
7. How will the patient tell us that he/she has to go to the bathroom?
8. How will the patient tell us that he/she is hungry or thirsty?
9. How will the patient tell us if he/she is in pain? Talking
Sign language
Typed words
Handwritten words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Crying
Facial expressions (frowning, etc.)
Hitting or hurting self
Hitting or hurting others
Other
(check all that apply)
If other, please explain:
10. Are there other ways the patient will let us know that he/she is in pain? Yes No
If yes, what ways?
1. How should we greet the patient?
2. What is the best way for us to examine the patient? Communicate with the patient (using the favored communication method) before each step of the exam
List or count things that the doctor needs to do; i.e. 1-look at eyes, 2-look in ears, 3-listen to heart, etc
Do parts of the exam on someone else first
Allow the patient to touch any instruments (i.e. stethoscope, blood pressure cuff) him or herself)
Hide instruments until their use becomes necessary
Distraction the patient from the examination
Other
If other, please explain:
3. Is there a part of the exam that may especailly bother the patient? Using a stethoscope to listen to lungs
Checking blood pressure with the cuff
Eye test
Ear test
Looking in mouth/throat
Belly Exam
Testing reflexes
Other
(check all that apply)
If other, please explain:
4. Will the patient wear a hospital gown? Yes No
If no, what would the patient want to wear?
5. Will the patient wear a hospital ID band on their wrist? Yes No
If no, please let us know before the patient comes to the hospital to discuss options since all patients must where a hospital ID.
1. Is the patient sensitive to: Loud noises
Unexpected noises
Bright lights
Specific colors
Fragrances/smells
Textures
Touch
Specific types of touch
Other
(check all that apply)
If other, please explain:
2. How long does the patient usually sleep at night?
3. Will a family member or caregiver be staying with the patient? Yes No
If yes, what hours will the caregiver be at the hospital?
4. Are there special ways to make mealtimes easier? Yes No
If yes, what ways?
5. Is the patient on a special diet? Yes No
If yes, what type?
6. Are there special times of the day that the patient eats snacks or meals? Yes No
If yes, what times?
7. Does the patient prefer that different foods in a meal not touch, or to have separate plates for each type of food? Yes No
If yes, what does the patient like?
8. Are there any words, phrases or actions that will upset the patient? Yes No
If yes, what are they?
9. How will the patient let us know if he/she is upset/anxious? Talking
Sign language
Typed words
Handwritten words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Facial expressions (smiling, frowning, etc.)
Physical motions (rocking, flapping, squeezing hands)
Hitting or hurting self
Hitting or hurting others
Other
(check all that apply)
If other, please explain:
10. What comforts the patient when he/she gets upset or anxious? Talk to him/her
Leave him/her alone
Give him/her some space
Other
(check all that apply)
If other, please explain:
11. What may help decrease the patient's anxiety? A map of the hospital
Low Lighting
Sunglasses
Headphones to decrease noise
A heavy blanket
An escort that will help the patient around the hospital
Music
Videos
Puzzles/games
Other
(check all that apply)
Please Explain
12. Are there any other safety concerns we should know about? Yes No
If yes, what are the concerns?
13. Is there anything else we should know about so we can make the patient's visit as positive as possible?
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