PARKSIDE COMMUNICATION QUESTIONNAIRE

Wewant to improve the way we communicate with our patients. We want to make sure we give you

informationthat you can easily understand.

We would be grateful if you, or someone on your behalf, would complete the questionnaire below and

giveto Reception. Please complete, even if you think we may already this information.

Patientname
Date of birth
Signed
Printname (if you are not the patient)
Date completed

8 / Uselipspeaker?
9 / Usetextphone?
10 / Preferonly to be written to? If so, by
emailor post?
11 / Usea personal Communication Passport?
12 / Usea deafblind intervener?
13 / Needslow spoken communication?
14 / Needloud spoken communication?
15 / Needyour medication labels in large
font?
16 / Other
Due to a communication difficulty/disability, how would you like us to contact you, and how would
youlike to contact us?
1 / Bytelephone
2 / Bytext message
3 / Byemail
4 / Bywritten letter (post)
5 / EasyRead
6 / Other
Due to a disability, would you require information in the following formats?
1 / Largefont (28 point sans serif font)
2 / EasyRead
3 / DVD
4 / USBstorage device
5 / Electronicdownloadable format
6 / Audiocassette tape
7 / Moonalphabet
8 / Makaton
9 / Braille(Grade 2)
10 / Braille(Grade 1)
11 / Other
Doyou require acommunication professional?
1 / Interpreter– British Sign Language
2 / Interpreter– Makaton sign language
3 / Anadvocate
4 / Signsupported English interpreter
5 / Deafblindcommunicator guide
6 / Deafblindmanual alphabet interpreter
7 / Deafblindblock alphabet interpreter
8 / Deafblindhaptic communication
interpreter
9 / Manualnote taker
10 / Lipspeaker
11 / Visualframe sign language interpreter
12 / Hands-­‐on signing interpreter
13 / Speechto text reporter
14 / Other
If youhave no communication needs, please tick here