Reasonable Adjustments Form - Bilston Health Centre

Health and Care organisations must make reasonable changes to their services so they can be accessible to people with disabilities. This includes people with a Physical, sensory, learning, or mental disability, including Dementia and Autism.

We are actively reviewing our processes and have created a more robust process for identifying and recording Reasonable Adjustments.

Please see the online questionnaire and consent form to tell us about any Reasonable Adjustments you may have.

Step 1 of 10

10%

Condition/ Disability/ Significant impairment to which this reasonable adjustment request relates to Optional

Patient Assessment

Communication Support

Does lip read Optional

Does use a communication device (please specify) Optional

Does use a hearing aid Optional

Preferred method of communication written Optional

Uses a citizen advocate Optional

Uses a legal advocate Optional

Uses an alternative communication skill (please specify) Optional

Uses British Sign Language Optional

Uses deaf blind intervenor Optional

Uses electronic note take Optional

Uses lip speaker Optional

Uses Makaton Optional

Uses manual note taker Optional

Uses personal audio device to record information Optional

Uses speech-to-text reporter Optional

Uses telecommunication device for the deaf Optional

Uses a non-speech system for communication (please specify) Optional

Uses functional communication skills (body language) Optional

Uses gestures for communication Optional

Uses non-verbal communication Optional

Uses objects for communication Optional

Uses photographs for communication Optional

Uses symbols for communication Optional

Uses verbal communication Optional

Uses voice-aid to support communication Optional

If patient does use a communication device, please specify Optional

If patient uses an alternative communication skill, please specify Optional

If patient uses a non-speech system for communication, please specify Optional

Requires Interpreter

Spoken language interpreter needed Optional

BSL interpreter needed Optional

Hands-on signing interpreter needed Optional

Makaton sign language interpreter needed Optional

Needs an advocate Optional

Requires deaf blind block alphabet interpreter Optional

Requires deaf blind communicator guide Optional

Requires deaf blind haptic interpreter Optional

Requires deaf blind manual alphabet interpreter Optional

Requires lip speaker (lip reading) Optional

Requires manual note taker Optional

Requires sighted guide Optional

Requires speech-to-text reporter Optional

Sign-supported English interpreter needed Optional

Visual frame sign language interpreter needed Optional

Contact & Information

Requires Specific Contact Method

Requires contact by email Optional

Requires contact by letter Optional

Requires contact by short message service text message (SMS) Optional

Requires contact by telephone Optional

Requires contact by text relay Optional

Requires contact via carer Optional

Requires Specific Information Format

Requires information by email Optional

Requires information in contacted grade 2 braille Optional

Requires information in easy read Optional

Requires information in Makaton Optional

Requires information in un-contracted grade 1 braille Optional

Requires information verbally Optional

Requires 3rd party to read out information Optional

Requires written information in big font size (please specify size) Optional

Requires information in different language (please specify) Optional

If patient requires written information in a big font size, please specify size Optional

If patient requires written information in a different language, please specify size Optional

Additional Communications Support

Difficulty analysing information Optional

Uses apps on mobile device to support communication Optional

Difficulty processing information at normal speed Optional

Difficulty processing information accurately Optional

Needs assistance with communication Optional

Requires appointment reminders Optional

Has my health care passport (hospital passport) Optional

Expresses pain atypically Optional

Requires carers to be present at encounters Optional

Is an interpreter required? (please specify what language) Optional

If patient requires interpreter, please specify language Optional

Additional Support Requirements

Adjustments for Providing Additional Support to Patients

Has appointed person with personal welfare LPA Optional

Requires constant supervision Optional

Unsafe to be left alone Optional

Care to be delivered in consultation with the patients carers Optional

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

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

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

Requires additional staff resource for their sensory impairment Optional

Requires additional staff resource for their physical impairment Optional

Requires additional staff resource for their mental impairment Optional

Adjustments for Providing Additional Support to Patients

Preference for male health care professional Optional

Preference for female health care professional Optional

Needle phobia Optional

Dependence on seeing eye dog Optional

Requires priority appointment Optional

Requires extended appointment Optional

Patient requires minimal waiting time between arrival and being seen Optional

Requires first appointment Optional

Requires last appointment Optional

Requires home visits where possible Optional

Requires distraction for any procedure Optional

Requires familiarisation for procedures Optional

Requires familiarisation with environment of care Optional

Has anxiety related to clinical settings Optional

Adjustments to The Environment

Noise intolerance Optional

Photophobia Optional

Eyes sensitive to light Optional

Requires wheelchair access Optional

Requires low-light environment Optional

Requires single room during inpatient care Optional

Bespoke Reasonable Adjustments

Requires reasonable adjustments for health and care access (Equality Act 2010) Optional

If patient requires reasonable adjustments not recorded elsewhere, please specify Optional

Patient Information & Consent

Patient Consent

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 happy for this to be shared with other organisations in the NHS?

Yes

Name

First Optional Last Optional

Date of Birth

Day

Month

Year

Address

Street Address Address Line 2 City County Post Code

NHS Number (If known) Optional

Please fill out the below if applying on behalf of patient

Best Interest Decision

Name

Role

Names of others involved in the Best Interest Decision to create or amend the Reasonable Adjustment Flag

Additional Roles

Lasting power of attorney for health and welfare Optional

Deputy Optional

Parent Optional

Legal guardian Optional

Independent advocate Optional

Please indicate if any of the following roles apply where applicable

Any Further Information? Optional

Are you happy for this to be shared with other organisations in the NHS and social care that will be involved in your care (National Care Records Service)?

I consent this information to be shared Optional

I do not consent this information to be shared Optional

Bilston Health Centre team will review this and respond within 30 days Optional