Help us to get to know you better

If you are a patient of Locala Dental Care and you have additional needs, it might be helpful to fill in our Patient Passport.

The information you give helps us to make your visits as good as they can be.

The more we know, the more we can help.

For a downloadable version of this form please click here.

Locala Patient Passport

About you

My name: *

Date of Birth *

I like to be called: *

I live with: *

Are you child or young person? *

Yes

My legal guardian is: *

Language/s I speak: *

Language/s I understand: *

Language/s my carer speaks: *

Language/s my carer speaks/understands: *

Things I like to do and talk about: *

Things I don’t like to do and talk about: *

School:

College:

Day services:

Learning Disability Team:

Disability Team:

Social services:

Speech and Language Therapy:

Any other services:

About my health

If I need emergency treatment you should know: (For example: I have epilepsy, diabetes, asthma, mental health illness, take anti-coagulants, other) *

I am sensitive to: *

How you can help me: *

Are there any helpful tips to support me when having medical/dental treatments? *

Any heart or breathing difficulties? *

How I take medication: (For example: Crushed, injected, syrup, with food, other) *

Please bring a list of the medication you take now

Previous experience in hospital or with illness you would like us to know about: *

How I communicate

I communicate by: (For example: Speaking, signing, pictures, objects, facial expression, behaviour, other) *

To help me understand what is happening and what treatment I need please use: (For example: Easy words, photos, signs, pictures, objects, video, other) *

If I seem worried, angry or upset, I may: *

You can help me with this by: *

I will let you know I am in pain by: (For example: Telling you, pointing, being noisy or quiet, crying, self harming, other) *

About my hearing: (For example: I have a good or not so good side, I am sensitive to noise, I need to see your lips when you speak to me, other) *

About my sight: (For example: I have a better side for you to approach me from, I wear glasses, lenses, certain lights bother me, other) *

Eating and drinking

How I eat: (For example: Food liquidised, mashed, cut small, cooled, support needed, special equipment needed, other) *

Foods I like: *

Foods I don't like: *

Special diet: *

Risk of choking when eating, drinking and swallowing: *

How I drink: (For example: Small amounts, thickened, special cup, cooled, other) *

Drinks I like: *

Drinks I don't like: *

Personal care

About my personal care: *

I can manage on my own: *

I need help and support: *

I need reminding: (For example: Toothbrushing, washing, bathing, dressing, other) *

How to help me moving around: (For example: Posture, transfers, walking aids, hoisting equipment, other) *

Date: *

Review date: *