Reasonable adjustments questionnaire

What size large print do you need?

Do you use grade 1 or grade 2 braille?

Please tell us how you would like to be contacted

Please tell us anything else staff need to know to contact you in a way that works for you

For example: Please text me and my carer the information we need. Please text me or use relay because I cannot hear. Send me information in plain English.

Support at appointments

I use a guide dog

I use a seeing eye dog

I need to bring my carer, family member, partner or friend

I use an advocate at appointments

I need an interpreter at appointments

Do you need us to arrange an advocate?

Yes

What type of interpreter do you need?

For example, sign language, lip speaker, deafblind interpreter.

What language do you need?

If you need support at appointments, please tell us what

For example: I have a support dog that I like to bring with me when possible. If I cannot bring my dog, I need to be told so I can arrange for someone else to come with me.

When you communicate with me

I need a longer appointment

I do not always understand information well

I need information written down

I need information explained using words (verbally)

I need information in an accessible format (for example large print, braille, audio, easy read or plain English)

I need things explained slowly and clearly

I need you to check I understand information

Please tell us what format you need

For example large print, braille, audio or easy read.

Is there anything else we need to know about how to support you to understand information in the best way possible for you?

For example: I need you to explain information in a clear and simple way and check that I have understood it. I need information written down so I can look at it later. I may need easy read or plain English information. I may also need more time at appointments to understand.

How I communicate what I need, want or feel

I use a device to help me communicate

I need more time to communicate

I need someone with me who knows me well to help me communicate

I am not able to communicate by phone

I communicate in a different way

I have a communication passport

Please specify

Please tell us how staff can support you with communication

Sensory differences

I need a low light environment

I need a low noise environment

I have another sensory difference

I feel pain in a different way to other people

Please specify

If you have a sensory difference, please tell us what staff can do to help you

For example, I need a low light room and low noise. I need to wait in the car for my appointment, so I do not get overwhelmed. I do not like to be touched, please tell me in advance if you will need to touch me. I need to use ear defenders to block out noise.

Hearing

Please specify

If you are deaf, hard of hearing or have another hearing difference please tell us what staff can do to help

For example, I use sign language and will need an interpreter. I use Makaton and have someone who can help me communicate with you. I use a hearing aid and hearing loop. I lip read.

Vision

I need someone who can see with me so they can help me move around (sometimes this is called a sighted guide)

If I need to be told something, please tell me with sound (for example call my name)

I use text relay

I have another difference in my vision

Please specify

If you are blind, partially blind, or have another difference in your vision please tell us what staff can do to help you

For example, I use a cane. I can see some shapes. I need my guide dog with me or someone with me to support me. Please tell me if you are going to touch me as I will not be able to see this.

How are you able to move your body?

I need buildings to be wheelchair accessible

I use an aid to move, such as crutches, a walking stick, or a wheelchair

I have some pain when I move some parts of my body

How I am able to move my body changes on different days

Please tell us what staff can do to help you or what buildings need to have so you can access them

For example, I am not able to use the stairs so need a ramp or lift. I need an accessible toilet, but it needs to be large enough for my carer too such as a changing places toilet. I need a soft chair to sit on. I am not able to straighten my arm for blood test so will need blood taken out of another part of my body.

Planning before an appointment

I have a Health and care passport or hospital passport

I have an Anticipatory care plan (this is a plan you and staff will make if there is a risk of something happening with your health)

I find it difficult going to new places so need to see the place I will be going to before I go to an appointment

I need to be told before my appointment exactly what will happen

I need to be seen as soon as possible as waiting can cause me a lot of stress

I need a visit at home

I need my own room if I am staying overnight

Please tell us what staff can do to support you before an appointment

For example, If I am going somewhere new it helps to have a video walkthrough or images so I can see what it will look like.

Medication

I need large print medication labels

I need a reminder sheet to tell me how to take my medication

Please say what size if you know

Please tell us what staff can do to support you with medication

For example, I need medication put into a box that shows which ones I take in the morning and the evening. I need help to make a plan so I know when exactly to take my medication and what times I should eat.

Is there anything else you need that you have not told us about?

Confirmation

I have read and understand about having my needs written on my health record on the computer.

Would you like a reasonable adjustment flag on your record?

Yes – I would like a reasonable adjustment flag

No – I do not want a reasonable adjustment flag

Would you like your adjustments to be shared with other teams in the NHS or social care?

Yes – I would like my adjustments to be shared

No – I do not want my adjustments to be shared

Signature:

Date:

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Reasonable adjustments questionnaire