Date completed: Completed by:
This document belongs to me. Please return it to me or my carer.
Nursing and medical staff please look at my passport before you do any
interventions with me.
1 Things you must know about me
2 Things that are useful to know about me
3 My likes and dislikes
I am NDIS registered:
Health Passport
Capturing important information about me and my health care needs.
If I have to go to hospital this book needs to go with me, it gives hospital
staff important information about me. It needs to be available to staff and
a copy should be put in my notes.
This is my
Hospital Identier:
My name is:
About the person completing this health passport
Details of the person or carer completing this health passport
Full name*
Address*
Organisation
Suburb*
Phone number*
Post code*
Carer Sibling
Self Spouse/partner
Parent Relative
Relationship to patient*
Next of kin
Legal guardian
Other
* Mandatory eld
Photo of Patient
Things you must know about me
Details of the person in this health passport
First name*
Phone number* Other*
Address*
Gender*
Email address*
Date of birth*
State*
Male Female
Please click one
I like to be known as*
Suburb*
Surname*
Age*
Post code*
Supported accommodation
Lives alone
Family
Private facility
Lives with paid carer Residential aged care
Lives with other unrelated people Lives in public housing
Lives with unpaid carer
I live with*
Other
IRN*Medicare Number*
Things you must know about me
Best contact person/s (e.g. next of kin)
Full name Relationship to patient Phone number
My health documents
The time may come possibly through sudden injury or serious illness – when
you cannot speak for yourself. These documents record your wishes about your
future health care and/or appoint someone to make decisions for you if you
were unable to make them for yourself.
I have the following health documents*
Things you must know about me
Please click one
Advance Health Directive/Statement of choice
Advance Care Plan document
Adult Guardianship/Enduring Power of Attorney
Resuscitation plan
Please bring copies of any documents with you to hospital.
Full Name
Contact
Relationship
Enduring Power of Attorney
No
Other
Things you must know about me
My doctor or general practitioner (GP)
Full name*
Practice*
Address
Phone number
Allergies or adverse reactions*
Yes No Unsure
Please click one
And/or
Details
e.g. heart, breathing
Things you must know about me
Medical problems*
Medical history and treatment plan*
Medical assessments
Please advise of major surgeries, medical interventions and current care plans.
e.g. the best way on how to undertake assessment with me….
Yes No Unsure
Please click one
Medications*
I take medications?
Things you must know about me
Yes No Unsure
Please click one
Medication name Dose and frequency Purpose (if known) How taken
Risk of choking or dysphagia
(eating, drinking or swallowing) difficulties
Blood group
My cultural background and spiritual beliefs
I have difficulties eating, drinking or swallowing?*
Please click one
e.g. ethnicity
Details
Things you must know about me
UnsureA B OAB
Yes No Unsure
Please click one
Hindi
Samoan
English
Mandarin
Spanish
Vietnamese
Language
Other
My communications style
I can usually communicate verbally?*
Speaking directly to me
Short plain sentences
Taking time to tell me
Simple words
Writing down notes in my care plan
Diagrams or pictures
Asking my supporter/carer
to explain it to me
Waiting for me to respond
Concrete examples
Asking me to explain it
Knowing I cannot talk but can hear
and understand
Checking to see if I understand
Using real objects
Giving me a demonstration
Please communicate with me by
This is what helps me to understand you
Things you must know about me
Yes No
Please click one
My communication system
(if yes, please name the system in other)
Symbols
Gesturing
When you wait for
me to respond
Pictures
Simple words
Facial expressions
My supporter/carer
This helps me to talk to you
Other
Normal behaviours for me
Things that make me anxious or nervous and what to do
e.g. sometimes I grunt and groan and rock back and forth but this is normal for me
How you know I am in pain
e.g. when I rock back and forth in my chair it usually means I am uncomfortable
or distressed which can be due to pain
I will tell you I am in pain by
I will show you I am in pain by
Things you must know about me
Things that are useful to know about me
Identified disabilities
Please select all appropriate
Development delay
(only for children 0 - 5)
Intellectual impairment
Physical disability
Acquired brain injury
Specic learning
(other than intellectual)
Autism spectrum disorder
(including Asperger’s)
Please click one
Level of support required
Please select below
Full support
(require full care for all day to day activities)
Partial support dependent
(require intensive assistance but can do some activities for myself - cannot be left alone)
Partial support with independence
(require some assistance and can do some activities - can be left alone)
Occasional support
(lives independently with some support)
Limited support
(requires some daily assistance but mostly independent)
Completely independent
Other
Please mark with an “x”
Neurological
(including epilepsy and Alzheimer ’s disease)
Deaf or blind
(dual sensory)
Other
Support person(s) and their role
Things that are useful to know about me
Full name
Relationship
to patient
Their role in
your care
Phone number
Services/professionals in my care
My mobility and falls risk
How I use the toilet
e.g. walk with assistance, need to be wheeled in wheel chair
e.g. continence aides, help to get to the toilet
Things that are useful to know about me
Full name Occupation/role Phone number
How I drink
e.g. small amounts, thickend uids, straw
Seeing/hearing
e.g. problems with sight or hearing?
Personal care
How I eat
e.g. dressing and washing
e.g. food cut up, pureed, help with eating
Things that are useful to know about me
How to keep me safe
My comfort items
Sleeping
e.g. bed rails, support with challenging behaviour etc.
e.g. things that reduce my anxiety
e.g. your sleep pattern/routine
Things that are useful to know about me
My likes and dislikes
Things that I like and make me feel comfortable
Things I dislike and make me feel uncomfortable
e.g. being talked to softly, background music, having my mum with me etc.
e.g. sudden loud sounds frighten me, being left alone etc.
Notes
Other information I would like to share?
e.g. routine
My likes and dislikes
Notes
© West Moreton Hospital and Health Service, 2016.
Adapted with permission from hospital passport concept developed by the Health Facilitation Team, 2gether NHS Trust
(formally Gloucester Partnership NHS Trust). The Picture Communication Symbols ©1981-2015 by Mayer-Johnson LLC.
All Rights Reserved Worldwide. Used with permission.
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