just a sample - My Health My Communication

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just a sample

1Introduction

2 About Me

3About My Disability

4How I Communicate

INTRODUCTION

This assessment will assist you to create your My Health My Communication Handover form. There are a lot of questions and you can choose answers that will tell your health care and support workers about your disability, health conditions and disorders. Your answers will be added to the handover form as a short story about you so that your health and disability support providers can quickly read and understand all the important things they need to know about you.

Watch the video below before starting the form.

Save and Resume Later

Things the hospital must know about you

In this section we will put together your personal details. This is the information that the hospital will need to know at admission.

We will also ask you to upload a picture. A picture of your face can help healthcare workers to know that this form belongs to you,

Watch the video below for more information.

Let's get your picture!

Click or drag a file to this area to upload.

What is your full name? *

First

Middle

Last

When is your birthday? *

What is your address? *

What is your postal address?

What is your email?

What phone numbers can we call you on? *

Save and Resume Later

In this section we would like you to tell us more about your disability

This will help the people supporting you to provide you with the best possible care.

Watch the video below for more information.

Do you have an intellectual disability? *

Yes
No

What level is your intellectual disability? *

Mild Intellectual Disability (IQ 50-55 to 70)
Moderate Intellectual Disability (IQ 35-45 to 50-55)
Severe Intellectual Disability (IQ 20-25 to 35-40)
Profound Intellectual Disability (IQ under 20-25)

Please choose if any of these are a cause of your intellectual disability *

Developmental Delay
Acquired Brain Injury
Congenital Disorder
Complication During Pregnancy or Birth
Toxin Exposure
Severe Childhood Illness

Save and Resume Later

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternately, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

Copy Link

Email *

Jasbinder2022-09-06T04:59:19+10:00September 6, 2022|

The My Health My Communication project is funded by the Department of Social Services and developed in partnership between DARE Disability Support and Nepean Blue Mountains Local Health District.

Nepean Blue Mountains Local Health District

FOLLOW THE PROJECT

Contact Us

13-15 Scrivener Lane, Springwood NSW 2777

Phone: 02 4751 5266

Email: myhealthmycommunication@dareds.com.au

Copyright My Health My Communication 2023 | All Rights Reserved