I understand spoken information best when it is in:
I understand written information best when it is in:
When trying to reach me use: (check all that apply)
Email
Text message
TTY
Video relay
Speech to Speech relay
Landline phone
Cell phone
USPS mail [if not time-sensitive]
Patient portal
Other
I understand best when I get information (check all that apply):
In pictures
In writing (including accessible formats)
Explained to me
Shown to me (including reading aloud)
When viewing films and videos, I need:
Descriptive narration (i.e., audio description)
Captioning
Sign Language
During the visit, I need accommodations for:
Hearing
Seeing
Speaking
Understanding, remembering, and/or learning
Moving
Hearing
I use
Hearing Aids
Cochlear Implant
Other implant (e.g., Bone Anchored Hearing Aid)
Interpreter, Sign Language
Interpreter, Tactile
Certified Deaf Interpreter (CDI)
Service animal
Familiar person to provide communication support
Lipreading
Voice amplifier
Written notes
I need (outpatient)
Provider to speak to me face-to-face
Provider to frequently ask if I understand what has been shared
Reduced background noise
Interpreter, Sign Language
American Sign Language (ASL)
Pidgin Signed English (PSE)
Signed English
Certified Deaf Interpreter (CDI)
Tactile sign language
Video Remote Interpreter (VRI)
Communication Access Realtime Translation (CART)
Assistive listening device (e.g., Pocket Talker)
Speech-to-text application
Services provided in writing
Pad/pen or typing on a device for communication
Letter, word, picture, translator boards
Clear masks worn by providers
Qualified reader
Qualified note taker
Use visuals or visual scales for assessment (e.g., picture of body to point to for pain)
I need (inpatient)
Adapted nurse-call button
Provider who speaks to me face-to-face
Provider who asks if I understand what has been shared
Reduced background noise
Interpreter, Sign Language
American Sign Language (ASL)
Pidgin Signed English (PSE)
Signed English
Certified Deaf Interpreter (CDI)
Tactile sign language
Video Remote Interpreter (VRI)
Communication Access Realtime Translation (CART)
Captioned phone
Phone with amplified sound
Voice amplification device
Speech-to-text application
Written information
Pad/pen or typing on a device for communication
Letter, word, picture, translator boards
Clear masks
Qualified reader
Qualified note taker
Use visuals or visual scales for assessment (e.g., picture of body to point to for pain)
Hearing aid batteries
Instructions posted about my communication needs
Seeing
I use
Glasses
Familiar person to provide communication support
Sighted guide
Orientation and mobility aid (e.g., cane)
Walker
Service animal
Braille
Digital recorder
Large print
Screen reader
Magnifier
I need (outpatient)
Accessible examination rooms:
Clear pathways
Well lit environment
Reduced background noise
Large print
Written information (e.g., handouts) provided in Braille, large print, audio, or electronically
Orientation to the site, office, or clinic
Alternate text for digital images
I need (inpatient)
Accessible examination rooms
Clear pathways
Well lit environment
Reduced background noise
Access to a call button and orientation to its use
Orientation to room and surrounding area
Orientation and mobility aid (e.g., cane)
Large print
Information provided in:
Braille
Digital or audio format
Read aloud
Instructions posted about my communication needs
Speaking (Expressing)
I use
Gestures
Speech (it may be difficult to understand me)
Sign language
A familiar person to provide communication support
Communication board (e.g., Letter, word, picture, translator boards)
Writing
Speech generating device
Phone or tablet with a communication app
Voice amplifier
I need (outpatient)
Extra time to communicate (e.g., ask questions, confirm understanding)
Questions in advance (e.g., forms, questions providers will ask in my appointment) so I can prepare my responses
Support person who understands my speech
Providers that ask Yes/No questions
Written instructions with relevant graphics and/or pictures to take home after visits
Graphics/picture display(s) relevant to setting (e.g., communication board)
Qualified reader
Qualified note taker
Visuals or visual scales for assessment (e.g., picture of body to point to for pain)
I need (inpatient)
Adapted nurse-call bell
Instructions posted about my communication needs
Access to my personal speech-generating device or an application on my tablet/phone
Access to a hospital speech-generating device or an application on a tablet
Equipment to mount/position my communication system
Extra time to communicate (e.g., ask questions, confirm understanding)
Questions in advance so I can prepare
Support person who understands my speech
Providers that ask Yes/No questions
Graphics/picture display(s) relevant to setting (e.g., communication board)
Word/alphabet display
Qualified reader
Qualified note taker
Visuals or visual scales for assessment (e.g., FACES or picture of body to point to for pain)
Understanding, Remembering, and/or Learning
I have difficulty with:
Preparing for appointments
Understanding instructions
Remembering instructions
Thinking of the right words
Putting thoughts together
Following directions
Speaking clearly
Asking questions
I need: (outpatient)
Providers to frequently check that I understand
Visual supports to help me understand
Writing/typing to remember information
Schedule longer appointments
Qualified reader
Qualified note taker
Visuals or visual scales for assessment (e.g., picture of body to point to for pain)
I need: (inpatient)
Providers to frequently check that I understand
Instructions posted about my communication needs
Visual supports to help me understand
Write information to help me understand
Extra time for interactions/procedures
Qualified reader
Qualified note taker
Visuals or visual scales for assessment (e.g., picture of body to point to for pain)
A referral to speech-language pathology or occupational therapy
Moving
Wheelchair
Scooter
Walker
Cane
Braces
Prosthesis
Service Animal
Stretcher
Oxygen
Ventilator
I need (outpatient)
Accessible building and examination room
Assistance transferring to equipment
Accessible exam/treatment table or chair [height adjustable]
Accessible imaging equipment
Accessible scale
Accessible bathroom or changing table
Assistance with transfers
Bariatric
Wheelchair
Lift equipment
I need (inpatient)
Accessible room
Accessible bathroom
Accessible nurse-call button
Assistance with transfers
Accessible exam/treatment table or chair [height adjustable]
Lift equipment
Air mattress
Bariatric bed
Wheelchair
Lift equipment
Instructions posted about my communication and physical access needs
Access to communication tools within my reach/view
Equipment to mount/position my communication tools (e.g., phone, call bell, communication system)