Reasonable Adjustments Request

Patient Information and Consent

Patient Name(Required)

First Last

Date of Birth(Required)

NHS Number (if known)

Patient's Phone Number

Patient's Email Address

Patient's Address

Street Address Address Line 2 City Post Code

Are you filling out this form on behalf of a patient?(Required)

Yes

No

Your Name

First Last

Your Phone Number

Your Email Address

What is your relationship to the patient?

Patient Consent(Required)

Does the patient consent to their reasonable adjustments being recorded in this way?

If the patient doesn’t have capacity, is it being done in the persons best interests?

Are you/the patient happy for this to be shared with other organisations in the NHS?(Required)

Yes

No

Additional Communications Support

Tell us about any other communications support you need, or things we should be aware of.

Difficulty analysing information

Uses apps on mobile device to support communication

Difficulty processing information at normal speed

Difficulty processing information accurately

Needs assistance with communication

Requires appointment reminders

Has my health care passport (hospital passport

Expresses pain atypically

Requires carers to be present at encounters

Please tick all that apply.

Additional Support Requirements

Is there anything else we need to know about providing additional support?

Has appointed person with personal welfare LPA

Requires constant supervision

Unsafe to be left alone

Care to be delivered in consultation with the patients carers

Requires additional staff resource for their sensory impairment (please specify)

Requires additional staff resource for their physical impairment (please specify)

Requires additional staff resource for their mental impairment (please specify)

Please tick any that apply.

Tell us about requirements for additional staff resource for sensory impairment

Tell us about requirements for additional staff resource for physical impairment

Tell us about requirements for additional staff resource for mental impairment

Additional Adjustments

If there are other reasonable adjustments that would help, please tell us about them here