Request to Record Reasonable Adjustments

This document is for people who are seen as having a disability under the Equality Act (this could be a physical or mental disability). Even if you do not see yourself as having a disability, or do not have a diagnosis, the Equality Act may see you as having a disability.

If you have a disability, sometimes changes are needed to the way healthcare staff care for you. These changes make it easier for you to be able to get the care you need in a fair way. We call these changes reasonable adjustments. This document helps staff record the changes you need. If you need support to fill this in, you can ask someone you trust to help.

The reasonable adjustment digital flag is a flag that shows up when health and care staff search for someone's health record on a computer, tablet or phone. It will show staff what changes you need and it will help more people get the changes they need.

The questions below are to help you think about the changes you need so staff can put them on your reasonable adjustment digital flag. This is not a way to tell staff about medical conditions you have as this will already be on your medical records.

You can tick as many of the tick boxes that are true for you. It is important to put detail in the box below each question to make sure staff can record how to make changes to support you. You do not need to answer all the questions.

There is a box at the end to add any other reasonable adjustments that you may need.

Practice Statement

Please be aware that we may not always be able to put all your requests in place, but we will make every effort to support you as best we can
Your Details

Full Name

Address

Date of Birth
For example, 15 3 1984

Day

Month

Year
Communication

How would you like to be contacted by the practice team? (optional)

By email

By letter

By telephone

Text message

I have no preference

Tell us about any additional communication needs (optional)

Hearing loop

Large print

Easy Read

Speak with my family member or carer

Other (you can tell us about this at the end of the form)

Is there anything that would help how we communicate with you? (optional)

I do not always understand information well

I need information to be written down or printed

I need you to tell me information slowly and clearly

I need you to check that I have understood the information correctly

Tell us how you best communicate what you need (optional)

I use a device to help me communicate

I use a hearing loop

I need more time to communicate

I need to see the same person who knows me best

I am not able to communicate by telephone

I have a hospital/Healthcare Passport

Other (you can tell us about this at the end of the form)
Sensory Needs

Tell us about any sensory needs (optional)

I need a low light environment

I need a low noise environment

I need a separate/quite space to wait for my appointment

Other (you can tell us about this at the end of the form)

Hearing (optional)

I am deaf or hard of hearing

I use a hearing aid

I lip read

I use a hearing loop

I use BSL sign language

I use Makaton sign language

Other (you can tell us about this at the end of the form)

Vision (optional)

I am registered blind

I am registered partially sighted

I need someone to help me move around

Please communicate clearly by sound

I need large print

Other (you can tell us about this at the end of the form)
Mobility

Please tell us if you have any problems with mobility (optional)

I use a wheelchair and need rooms to be accessible

I use a walking aid

I move slowly due to pain

I have a physical disability that affects my mobility

Other (you can tell us about this at the end of the form)
Appointments

Is there anything we need to know before your appointment? (optional)

I have a Hospital/Healthcare Passport

I have an Anticipatory care plan

I need to be reminded of my appointment

I struggle with new places and need to know where I will be going before my appointment

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

I would prefer to be given the first clinic appointment as waiting causes me anxiety

Morning appointments are better for me

Afternoon appointments are better for me

I need a longer appointment

Other (you can tell us about this at the end of the form)

Support at appointments (optional)

I use a guide dog

I need to bring a family member, friend or carer with me

I use an advocate at my appointments (please tell us this when you book)

I need an interpreter at appointments (please tell us this when you book)
Medication

Tell us about any help you need with medication (optional)

I need someone else to order my prescription for me

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

I need a dosette box so that I know when to take my medication

I struggle to swallow and need liquid medication where possible

Other (you can tell us about this at the end of the form)
Additional Information

If you have answered 'other' in any of the questions above, please give us further details below (optional)
Sharing your Reasonable Adjustment preferences

We can record your reasonable adjustments on your NHS record. This creates a Reasonable Adjustments digital flag so other NHS services can see how to support you.

Summary care Record sharing enables other healthcare services that you see to view important details about your care. You can choose Core which is only basic information, or you can choose Additional which can help other healthcare professionals to provide you with more informed and effective treatment

Do you agree to us recording your Reasonable Adjustments in your medical record?

Yes

No

Are you happy for us to share your Reasonable Adjustments with other Healthcare providers?

Yes

No

Please tell us the level of record sharing you would like to consent to

I give consent for Core Summary Record sharing ONLY

I give consent for Additional Summary Record sharing

I DO NOT consent to sharing important medical information with other healthcare providers

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Request to Record Reasonable Adjustments

Request to Record Reasonable Adjustments

Practice Statement

Your Details

Communication

Sensory Needs

Mobility

Appointments

Medication

Additional Information

Sharing your Reasonable Adjustment preferences