My communication and health passport

My name is

I like to be called

My pronouns are

My date of birth is

I live

Who I live with

My parents or carer are called

What you need to know about my family

Our house telephone number is

Our mobile number is

The languages we speak are

My religion is

My ethnicity is

My allergies are

My doctor or GP is

The surgery address is

The surgery telephone number is

My school is

I need you to give me information in this way:

Easy Read
Braille
Phone call
Large print
Another language:

I need help to go to my appointments:

Wheelchair access
Hoist
I cannot walk far
I need to use a lift
I need an accessible parking space

I need more time at my appointment to understand information and instructions

I or my parent or guardian need an interpreter
in language:

When I come to the hospital I need help with:

A quiet place for me to wait for my appointment
I need the first appointment of the day, as I find waiting very hard
I need the last appointment of the day, as I need my daytime routine

This is how I communicate:

I use Makaton
I use British Sign Language
My parent or guardian with interpret my body language
I use a talk mat
I use electronic augmentative and alternative communication (AAC)

This is how you can help me understand information:

It helps me when I see pictures
Speak to me in short sentences and wait for me to reply
Do not use jargon. Use simple words to help me understand
Speak to my parent or guardian and they will explain it to me

Extra things about me and my reasonable adjustments:

The doctor or consultant who knows me best is

Other people or medical teams that help me are

These are my medical and neurological conditions:
I have a learning disability
I have autism
Other:

I was born a premature baby    No      Yes
I was born weeks premature

Help I need to take my medicine:

The medicate I take:

Help I need to stay safe:

Help I need with mobility or postural management:

Help I need to eat and drink:

I have a risk of choking
I have dysphagia

I have specialist nutritional needs    No      Yes

My feeding regime is:

I have a metabolic condition    No      Yes

This is my emergency plan:

Consent and support I need to make decisions:

I have an advanced care plan    No      Yes

I am enrolled in a clinical trial    No      Yes

I have epilepsy    No      Yes

My seizure and management plan is:

My breathing

I have a respiratory emergency plan    No      Yes

I have a tracheostomy    No      Yes

Size:
Type:
Length:
Suction tube:

My heart

I have congenital heart disease or cardiac problem    No      Yes

This is the help I need with my eyesight and hearing:

This is how to help me tell you about my pain:

This is how you can help me tell you about my feelings:

This is how you can help me and my sensory needs:

These are the things that make me feel anxious, worried or scared:

This is help I need to get washed and dressed:

This is the help I need to use the toilet:

This is the help I need to get to and stay asleep:

This is what I like, or what helps me:

This is what I dislike or avoid: