Reasonable Adjustment form - Appletree Medical Practice

Name

First Last

Address

Street Address Address Line 2 ZIP / Postal Code

Phone Optional

LANGUAGE ASSISTANCE

I need an interpreter or translator Optional

I use a device to communicate Optional

I prefer verbal communication only Optional

Difficulty reading / writing Optional

Prefer written communication only Optional

Prefer verbal communication only Optional

Other Optional

If you selected interpreter or translator – What language do you require? Optional

Any other information about language assistance? Optional

HEARING AND SPEAKING

I wear a hearing aid? Optional

I would like to use the practice hearing loop? Optional

Please could I have a BSL Interpretor? Optional

I lip read Optional

I use non-verbal communication Optional

I have difficulties with speech Optional

Any other information about hearing or speaking? Optional

SIGHT

I have sight loss or vision problems Optional

I would like assistance walking around the practice Optional

I would like to bring an assistance dog. Optional

Any other information about your sight? Optional

WHAT IS THE BEST WAY TO PROVIDE INFORMATION TO YOU?

Large text letters Optional

SMS Text messages Optional

Phone call Optional

Through a named third party person, such as a carer Optional

Any other information about how we provide information to you? Optional

PLEASE LET US KNOW IF YOU ARE AFFECTED BY:

Noise disturbance or intolerance Optional

Visual intolerance Optional

Physical difficulties Optional

Would you prefer a Male clinician? Optional

Would you prefer a Female clinician? Optional

Phobia or social anxiety Optional

Benefit from sensory / fidgets aids (box at reception) Optional

Any other information relevant to this section? Optional

DIFFICULTY OR HELP PROCESSING INFORMATION

I would like extra time to think Optional

I have a healthcare passport / hospital passport Optional

Any other relevant information? Optional

ANY OTHER INFORMATION? Optional

Please write down anything else that you think would help or that it would be useful for us to know, or more information about the points you have ticked above. If you have anything you would like to discuss further, please contact reception on 01332 842288

DIGITAL FLAG ON YOUR MEDICAL RECORDSWe would like to upload this information to a shared record, keeping staff up to date and informing other healthcare professionals of your needs.

Yes I am happy to have a digital flag on my record Optional

No, I do not want to have a digital flag on my record Optional

I give consent for this information to be marked on my shared record. Optional

Only complete this if you have answered YES to the question above and are happy to have a digital flag on your records

Reasonable Adjustment request

Reasonable Adjustment

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