My Hospital Passport

My Log-in Details
My email address*
My Password*
Enter a password of 6 or more letters, numbers and symbols.?
Important Information
My Title*
My first name*
Enter your full first name.
Example: Frederick, or Amy-Rose		?
My middle name(s)
Enter your middle names, if you have any?
My last name*
Enter your full last name (i.e. surname, or family name)?
I like to be called
Enter the name(s) you like to be called.
Example: Freddie or Fred		?
Known allergies
Enter any known allergies.
Example: Penicillin, nuts, and shellfish		?
My mental capacity
If you don't have full capacity to make decisions for yourself, summarise your capacity here.
Example: I do not have capacity to make medical decisions, but I can make all other decisions.		?
Decisions I can make
If relevant, describe what kinds of decision you can make for yourself (or leave this empty if you wish).
Example: I can decide if or when I take medications, or have blood taken.		?
Any Advance Decision?
If you have an Advance Decision (e.g. 'Do not attempt CPR'), give details of your wishes here.
Example: Do not attempt CPR or other life-saving interventions if I am unable to make decisions.		?
NHS/Healthcare No.
If you have one, or enter your NHS or Healthcare/Insurance number?
My Hospital's name
If you have one, enter your preferred hospital's name and location.
Example: Royal Infirmary, Glasgow		?
My Hospital Reg. No.
If you have one, enter your Patient Number from your preferred hospital?
My Personal Information
My date of birth
My gender (sex)*
My preferred pronouns
My address
Town or city
Region
Post/zip code
Country*
My mobile/cell no.
My home phone no.
My ethnic background
My religion (if any)
What is your faith, if any?
Example: Athiest, Christian, Muslim, etc.		?
My Emergency Contact's Details
Emergency contact
If you have one, enter the name and details of the person you want contacted in an emergency?
Their relationship to me
Their address
Town or city
Region
Post/zip code
Country
Their mobile/cell no.
Their home phone no.
Their work phone no.
Their email address
Languages they speak
What language(s) does your emergency contact speak??
My Doctor's Details
My Doctor's name
If you have one, please enter your doctor or physician's details?
Doctor's Practice name
Their address
Town or city
Region
Post/zip code
Country
Doctor's phone no.
IMPORTANT - READ THIS BEFORE CONTINUING!
Medical professionals don't have much time, so only put in the MOST important information, and keep it as brief as possible! Please don't be tempted to give as much detail as you can because it will be harder for them to remember everything. Stick to the basic facts and what's really important... try to keep it short!
My Medical Summary
Current medications
If you have any regular medications, please list them (and their dosage and frequency).
Example: Paracetamol 500mg x 2 four times a day, Metformin 500mg twice daily, Omeprazole 20mg in the morning.		?
Mental health problems?
If you have any mental health issues, please give details along with any medication or therapy you need.
Example: I have anxiety and depression, and take Mirtazapine 30mg at night		?
Epilepsy?
If you have Epilepsy, enter as much detail about your seizures and recovery as you can.
Example: I have nocturnal tonic-clonic seizures, and often have a headache beforehand. My recovery medication is Midazolam, which I keep in my purse		?
Diabetes?
If you are diabetic, say what type (I or II) and what medication and glucose monitoring system you use.
Example: I am type II diabetic, controlled by Metformin and diet, and I use Acme BG test strips twice a day.		?
Heart problems?
If you have any heart problems or irregularities, please give as much detail as possible here, along with any medications or devices you use.?
Respiratory problems?
If you have any respiratory problems, give details here, along with any medication or inhalers you use.
Example: I have asthma and use a Salbutamol inhaler when needed		?
Other organ problems?
If you have any problems with other organs (e.g. liver, kidneys, spleen, pancreas, etc) give details here, along with any medication or procedures you need to have.
Example: I am hyposplenic, so I take Erythromycin 250mg twice a day, every day.		?
Other medical conditions?
If you have any other medical conditions not already mentioned, please give details along with any medication or aids you might need.
Example: I have varicose veins in my legs and need to wear pressure stockings during the daytime		?
Current Treatment Plan
If you have a current Medical Treatment Plan, please give a summary of its main points and requirements?
Autism & Related Conditions
Am I Autistic?
?Tick this box if you are Autistic
Related conditions
?Please tick anything that's true for you.
   ADHD (Attention Deficit Hyperactivity Disorder)
Please be patient because ADHD means I may find it hard to concentrate.
   Anxiety disorders (Generalised Anxiety Disorder, Social Anxiety Disorder, etc.)
Please reassure me if I appear anxious about something.
   Depression
Please explain why things will be okay if I appear depressed.
   Obsessive-Compulsive Disorder (OCD)
Please be patient as OCD means I may be repetitive or distracted.
   Epilepsy
Please be aware I'm epileptic and monitor me for seizures.
   Sleep disorders (insomnia, sleep apnea)
Please offer me any necessary sleep aid at night (such as a CPAP or Bi-Pap machine, etc).
   Gastrointestinal issues (IBS, constipation)
Please offer me laxatives or IBS medication.
   Tics/Tourette's Syndrome
Please don't be offended if my speech patterns are repetitive or not appropriate.
   Sensory Processing Disorder (SPD)
If I'm behaving in unexpected ways, please ask me if I have any sensory problems.
   Learning Disability
Please explain information calmly and clearly, and check my understanding before continuing.
   Intellectual disability
Please explain information calmly and clearly, and check my understanding before continuing.
   Joint hypermobility syndrome/Ehlers-Danlos syndromes (JHS/EDS)
Please offer me mobility aids and comfortable seating.
   Eating disorders (anorexia, bulimia, ARFID)
Please ensure that I have adequate nutrition and fluids.
   Bipolar disorder
Please be patient and treat me kindly if my behaviour changes suddenly.
   Schizophrenia
Please be patient and treat me kindly if my behaviour or personality changes suddenly.
   Migraines
Please offer me pain relief and a quiet, darkened room if I have a migraine.
   Skin conditions (e.g. eczema)
Please be aware of skin conditions and use any appropriate treatments.
   Autoimmune disorders
Please monitor my temperature vital signs constantly in case I contract an infection.
   Pathological Demand Avoidance (PDA)
Please be patient when asking me to do things as I might resist your requests.
   Oppositional Defiant Disorder (ODD)
Please be patient when asking me to do things as I might resist your requests.
   Self-harm
Please monitor me regularly for any signs of self-neglect and self-harm.
   Suicidal ideation
Please monitor my mood, actions and speech to watch for suicidal thoughts, feelings or actions.
   Trauma/PTSD
Please be aware that I have suffered past trauma that affects how I feel about things now.
Sensory conditions
?Please tick anything that's true for you.
   Hypersensitivity to sounds
Please try to reduce the number and volume of sounds around me.
   Hyposensitivity to sounds
Please offer me ways of listening to music or pleasing sounds.
   Hypersensitivity to light
Please try to reduce the light levels and colours in my surroundings.
   Hyposensitivity to light
Please ensure my surroundings have good lighting and colours.
   Sensitivity to specific textures
Please ask me what textures I like and dislike.
   Hypersensitivity to tastes
Please don't give my food or drink that tastes strong.
   Hyposensitivity to tastes
Please try to offer me strong-tasting foods and drinks.
   Hypersensitivity to smells
Please try to reduce the strength and number of smells around me.
   Hyposensitivity to smells
Please provide me with foods, drinks, and things that smell strong.
   Proprioceptive differences (poor body awareness)
Please monitor me for any signs of pain or discomfort.
   Vestibular differences (balance and spatial orientation)
Please offer me mobility/stability aids, and clear signage.
   Sensitivity to internal sensations (e.g., hunger, pain)
Please ask me if there are any foods or drinks that I can't bear.
   Difficulty filtering sensory input
Please try to reduce the number of sensory stimuli in my surroundings.
   Synesthesia
Please be patient as I process some ideas, thoughts and feelings in unconventional ways.
My behaviours
?Please tick anything that's true for you.
   Repetitive movements (stimming)
Please allow me some privacy and try not to interrupt when I'm stimming.
   Intense interests/hyperfixations
Please be patient when I talk about or focus on my own interests intensely.
   Difficulty with social interaction
Please help guide me through person-to-person interactions.
   Difficulty with social communication
Please explain things or use visual aids when I struggle to communicate.
   Reliance on routines
Please be patient if I seem upset when I can't following my preferred routines.
   Difficulty with changes in routine
Please let me keep to my routines if possible, and explain any changes beforehand.
   Difficulties understanding non-verbal cues
Please be very literal with your words because I may not understand body language or figures of speech.
   Difficulties understanding sarcasm or irony
Please don't use sarcasm or irony when speaking to me; I may not understand their meanings.
   Echolalia (repeating words or phrases)
Please be patient if I seem to repeat words or phrases over and over.
   Literal interpretation of language
Please use very literal language as I may not understand sarcasm or figures of speech.
   Challenges with emotional regulation
Please be patient and allow me to vent my feelings as I may struggle to contain them.
   Difficulties with executive function
Please don't expect me to make decisions and follow them through without prompting.
   Sensory seeking behaviours
Please offer me different ways of experiencing sensory stimuli as I may crave them.
   Sensory avoiding behaviours
Please reduce the number of sensory stimuli in my surroundings.
   Special talents or skills
Please help me to use my special talents or skills as much as possible.
   Difficulties with eye contact
Please don't be offended if I don't make eye contact during conversation.
   Social withdrawal
Please allow me to choose when I'm ready to interact with others socially.
   Challenges with perspective-taking
Please prompt me when I don't seem to understand the rules of conversation.
   Strong sense of justice
Please be patient if my sense of right and wrong seems very 'black and white' at times.
   Challenges with imaginative play
Please be patient if I don't easily engage in imaginative play or discussions.
   Catatonia
Please be aware that I may suddenly become unresponsive or fall asleep.
   Aggression
Please be kind and patient with me, and gently explain when my behaviour seems too aggressive.
   Self-injurious behaviours
Please monitor me constantly for any signs of self-neglect or self-injury.
   Highly focused attention
Please be patient if I seem to pay unusually close attention to something or someone.
   Need for personal space
Please offer me as much personal space and privacy as I need.
   Uneven skill profile
Please be patient if my skills and behaviours seem changeable.
My Support Needs
My Support Plan/Needs
If you have one, enter a brief summary of your current Support Plan (i.e. what daily help you may need)?
Personal Care needs
Enter a summary of what Personal Care (if any) that you may need help with.
Example: I can shower independently but need help getting dressed. I can brush my own teeth, but need help shaving.		?
Mobility problems?
If you have any mobility problems, please give full details along with any mobility aids you use.
Example: I have chronic joint pain, and use a walking frame to move around		?
Eye-sight problems?
If you have any eyesight problems, please give details along with any medication or corrective glasses you need.
Example: I have astigmatism and I am short-sighted, and need to wear glasses all day		?
Hearing problems?
If you have any hearing problems, please give details along with any medication or corrective devices you need.
Example: I am 50% deaf in my left ear and 30% deaf in my right ear, and need to wear hearing aids		?
Eating/drinking problems?
If you have any eating, drinking, or nutrition problems, please give details.
Example: I have Barrett's Oesophagus and am at risk of choking, so I need my food cut up small.		?
Toileting problems?
If you have any problems using the toilet, please give details along with any help or equiptment you might need.
Example: I can urinate independently but need help cleaning up after passing stools		?
Sleep problems?
If you have any sleep problems, please give details along with any medication or equipment you need to use, and when.
Example: I have insomnia and obstructive sleep apnoae, so I need Diazepam 2mg before bed, and I use a CPAP machine every night		?
My Communication Needs
My languages/signs
Please say what language (or signing systems) you prefer to use.
Example: English, and Makaton/BSL		?
How I communicate
If you have particular ways of communicating your needs or wishes, please explain them here.
Example: I don't have many words, but I will gesture or use Makaton to tell you what I want		?
Communicating with me
Please explain how you would like others to communicate with you.
Example: Speak simple English, or use British Sign Language, or use visual aids		?
How I show I agree
If you aren't able to communicate verbally, please explain how someone else will know when you Agree with something.
Example: I will nod my head or give a thumbs-up		?
How I show I disagree
If you aren't able to communicate verbally, please explain how someone else will know when you Disagree with something.
Example: I will shake my head or give a thumbs-down		?
How I show I'm in pain
If you aren't able to communicate verbally, please explain how someone else will know when you are in pain.
Example: I will cry or hold my head in my hands		?
How I show I'm anxious
If you aren't able to communicate verbally, please explain how someone else will know when you are anxious.
Example: I will become quiet or hide myself away		?
How to help my anxiety
Please explain how somebody might help you if you're feeling anxious.
Example: Please reassure me, and explain or show me what is happening		?
How I show I'm in distress
If you aren't able to communicate verbally, please explain how someone else will know when you are in distress.
Example: I will shout or tremble		?
How to help my distress
Please explain how somebody might help you if you're distressed.
Example: Please ask me what's wrong, and try to help me or explain things clearly		?
Communication issues
?Please tick anything that's true for you.
   Difficulty initiating conversations
Please prompt me when a conversation starts, or when you want to talk.
   Difficulty maintaining conversations
Please prompt me when our conversation stalls as I might not know what to say next.
   Trouble understanding nonverbal cues (body language, facial expressions)
Please be explain things literally, or use visual aids.
   Difficulties with reciprocal conversation
If necessary, please prompt me about whose turn it is to talk next.
   Literal interpretation of language
Please use very literal language as I may not understand sarcasm or figures of speech.
   Difficulties understanding sarcasm or irony
Please don't use sarcasm or irony when speaking to me; I may not understand their meanings.
   Challenges expressing emotions verbally
Please watch for behaviour that suggests I can't express how I'm feeling.
   Challenges recognising emotions in others
Please explain what you're feeling when I don't seem to understand your emotions.
   Difficulties understanding social rules or expectations
Please prompt me when I don't seem to understand what's expected of me.
   Trouble with perspective-taking
Please prompt me when I don't seem to understand the rules of conversation.
   Difficulties forming and maintaining friendships
Please prompt me if I don't follow social rules for making or maintaining relationships.
   Tendency to talk at, rather than with, others
Please be patient if I dominate a conversation, and prompt me to let others talk too.
   Difficulties with joint attention
Please be patient if I struggle with thinking with you about something.
   Social anxiety
Please be patient and reassuring if I seem anxious about social interactions.
   Preference for solitary activities
Please allow me time and privacy for activities on my own.
   Avoidance of social situations
Please be patient and encouraging if I try to avoid social situations.
   Difficulties negotiating social situations
Please be patient and prompt me if I don't understand social expectations.
   Challenges with abstract language
Please use very literal language as I may not understand sarcasm or figures of speech.
   Social isolation
Please gently encourage me to mix with other people to avoid social isolation.
   Difficulties with flexible thinking in social situations
Please don't be offended if my viewpoint seems too 'black and white'.
   Delayed language development
Please use simpler language and consider using visual aids when talking to me.
   Atypical prosody (tone, rhythm, or intonation of speech)
Please be patient if my speech is slow, rapid or irregular in rhythm, tone, pitch or stress
   Echolalia (repeating words or phrases)
Please be patient if I seem to repeat words or phrases over and over.
   Use of scripted language
Please listen for subtext and check your understanding if I talk in 'scripted' phrases.
   Challenges in asserting boundaries
Please be aware that I may not form appropriate boundaries, and help me to figure them out.
   Overly trusting of others
Please monitor me to make sure others are not taking advantage of my trust-vulnerability.
   Difficulties sharing experiences
Please be patient and keep trying if I don't seem keen to share my experiences.
   Struggles with conflict resolution
Please help me to come to a compromise in a conflict as I may find this tricky.
My Likes and Dislikes
Things I like
If you want to, list things you particularly like (that make you happy).
Example: Watching TV, using my phone or tablet, listening to music, read comic books		?
Things I dislike
If you want to, list things you particularly dislike.
Example: Loud noises, surprises, people whispering, people eating crunchy foods near me, getting wet		?
Activities I like to do
If you want to, list any activities you might enjoy when you're in hospital.
Example: Watching films, using the internet, reading books and magazines, playing video games		?