Reasonable Adjustments Form

 
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All questions marked with a * are mandatory

Personal Details
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Accessibility Questions
Do you have a physical or mental impairment which has a substantial and long-term negative effect on your ability to do normal daily activities?: *

Substantial means more than minor or trivial, eg it takes much longer than it usually would to complete a daily task like getting dressed. Long-term means 12 months or more.

Do you require reasonable adjustments to enable you to access healthcare more easily?: *
Are you happy for the information regarding your disability and the reasonable adjustments you need to shared with other organisations in the NHS and social care that are involved in your care?: *

By consenting, this information will be uploaded to a 'Digital flag' on the national record within the NHS spine. This enables healthcare and social care professionals to be aware of your needs and make the same reasonable adjustments to accommodate these.

Do you have any communication needs? (Choose all that apply): *
Do you need adjustments in relation to your environment of care? (Choose all that apply): *
Do you speak a foreign language and need an interpreter?: *
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Thank You

We will endeavour to accommodate any reasonable adjustments you have mentioned and share this information with other organisations in the NHS and social care so they can do the same (assuming you have consented to this). If you need to update your reasonable adjustments please contact us. 

Privacy Consent

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