Individualized Adaptive Care Plan

By partnering with you, we will create an individualized plan to help your child have smoother and less stressful healthcare encounters. Please fill out this form to help us learn about your child so we can better meet your child’s needs. If you have any questions, please contact the Adaptive Care Team at adaptivecareteam@cchmc.org.
General Information
*
Patient Information
*
*
Healthcare Visits

1. Would you describe healthcare visits as easy or hard for your child?

2.) Which clinics/hospital areas are difficult for your child? Check all that apply.
Please specify
3. Are waiting and/or waiting areas stressful for your child?
5. Does your child have difficulty entering the hospital/clinic space?
Please specify
6. What is the best way for us to examine your child? Check all that apply.
Please specify
7. Is there a part of the exam that may especially bother your child? Check all that apply.
Please specify
8. Will your child wear a hospital gown?
Communication
1. How does your child communicate needs/wants? Check all that apply.
Please specify
2. How does your child best learn new information or understand instructions? Check all that apply.
Please specify
3. What is the best way to prepare your child for transitions? Check all that apply.
Please specify
4. How does your child communicate pain? Check all that apply.
Comfort and Safety
1. Is your child sensitive to:
4. How will your child let us know if he/she is upset or anxious? Check all that apply.
5. What comforts your child when he/she gets upset or anxious? Check all that apply.
Additional Information
1. How would you rate your stress when bringing your child to the doctor's office or hospital on a scale of 1 (least stress) to 5 (most stress)?
2. How upset or anxious does your child get at the doctor's, dentist's, or hospital on a scale of 1 (no anxiety) to 5 (severe anxiety and difficulty calming afterward)?
5. How much do you think your child understands about his/her visit on a scale from 1 (does not understand at all) to 5 (understands most aspects of visit)?