Care Plan | Adaptive Care Team

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

Name of person completing this form

Relationship to the patient

Email address of person completing this form

Phone number of person completing this form

Patient Information

Patient Name

Patient Date of Birth

Healthcare Visits

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

Please explain:

1a. Has your child had any visits that were particularly upsetting or hard for him/her?

2.) Which clinics/hospital areas are difficult for your child? Check all that apply.

Ophthalmology
Primary Care
OT/PT
Dental
Test Referral Center

Additional difficult clinics/hospital areas:

Please specify

3. Are waiting and/or waiting areas stressful for your child?

Yes
No

If yes, please specify:

4. How should we approach or greet your child?

5. Does your child have difficulty entering the hospital/clinic space?

Yes
No

Please specify which areas:

Please specify

6. What is the best way for us to examine your child? Check all that apply.

Communicate with your child (using the favored communication method) before each step of the exam
List or count things that the doctor needs to do (i.e. 1-look at eyes, 2-look in ears, 3-listen to heart, etc.)
Do parts of the exam on someone else first
Allow your child to touch any instruments (i.e. stethoscope, blood pressure cuff) him or herself
Hide instruments until their use becomes necessary
Distract your child from the examination

Other examination preferences:

Please specify

7. Is there a part of the exam that may especially bother your child? Check all that apply.

Listening to heart/lungs
Checking blood pressure
Eye exam
Ear exam
Looking in mouth/throat
Touching/feeling parts of the body for exam
Checking reflexes
Height
Weight
Head measurement
Sitting on the exam table/chair
Lying down
Procedures with needles (e.g. blood tests, shots, etc.)

Additional examination concerns:

Please specify

8. Will your child wear a hospital gown?

Yes
No

9. Will your child wear a hospital ID band on their wrist or ankle?

Communication

1. How does your child communicate needs/wants? Check all that apply.

Talking
Sign language
Typed words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Facial expressions
Guiding or leading by the hand

Other communication methods:

Please specify

2. How does your child best learn new information or understand instructions? Check all that apply.

Talking (single words, short phrases, simple/concrete language, etc.)
Sign language
Typed words
Handwritten words
Tablet or communication device
Stories
Pictures or symbols
Pictures with words
Visual schedule
First/Then Boards
Demonstration or modeling

Other learning methods:

Please specify

3. What is the best way to prepare your child for transitions? Check all that apply.

Using a clock or watch
Using a timer
Using a visual schedule
Counting aloud
Alternative transportation (wheelchair, wagon, etc.)

Other transition methods:

Please specify

4. How does your child communicate pain? Check all that apply.

Talking
Sign language
Typed words
Handwritten words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Crying
Facial expressions
Hitting or hurting self
Hitting or hurting others

Other ways to communicate pain:

Comfort and Safety

1. Is your child sensitive to:

Loud noises
Unexpected noises
Bright lights
Specific colors
Fragrances/smells
Textures
Touch
Crowds
Small spaces

Other sensitivities:

If sensitive to touch, please specify (light, firm, unexpected, all, specific body part(s), etc.)

2. Does your child have any sensory difficulties related to medical supplies or equipment on his/her body such as Band-Aids, pulse oximeters, IV lines, etc.? If yes, please explain.

3. What are your child’s stressors or triggers? Are there any words, phrases, or actions that will upset your child?

4. How will your child let us know if he/she is upset or anxious? Check all that apply.

Talking
Sign language
Typed words
Handwritten words
Tablet or communication device
Pointing/gesturing
Pictures or symbols
Pictures with words
Making sounds
Facial expressions
Physical motions (rocking, flapping, squeezing hands)
Hurting self
Hurting others (e.g. kicking, hitting, scratching, biting, etc.)
Attempting to escape

Other ways they may communicate being upset:

If you selected hurting self or others, please specify (e.g. scratching, head banging, etc.):

5. What comforts your child when he/she gets upset or anxious? Check all that apply.

Talk to him/her
Leave him/her alone
Give him/her some space
Preferred items
Preferred caregiver
Quiet space
Low Lighting
Sunglasses
Headphones to decrease noise
Deep pressure
An escort that will help the patient around the hospital
Pacing or going for a walk
Music
Videos
Puzzles/games
Food/drink

Other techniques to comfort:

6. What things does your child like? Are there any foods/toys/cartoon characters/rewards that may motivate your child's behavior?

7. How does your child adapt or respond to change (new settings, people, or routine)?

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)?

1
2
3
4
5

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)?

1
2
3
4
5

3. If your child gets very upset, how long does it take him/her to calm down afterward?

4. Does your child get anxious in other settings such as home, school, or the store?

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)?

1
2
3
4
5

6. Are there any strategies that you have found particularly helpful for anxiety producing situations (within or outside of healthcare visits) in the past?

7. Is there anything else that might be helpful for people to know about your child?

Adaptive Care | Care Plan

Individualized Adaptive Care Plan

Adaptive Care | Care Plan

Individualized Adaptive Care Plan

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