This passport belongs to me. Please return it when I am discharged.

1. This passport belongs to me. Please return it when I am discharged. Things you must know about me Things that are important to me My likes and dislikes My hospital passport My name is Write here… Replace with photo of person if possible; if not delete this box I like to be called Write here… 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 at the end of my bed. A copy should also be put in my notes. Nursing and medical staff please look at my passport before you do anything involving me. Page 1

2. Things you must know about me Completed by Date Review date Write here… Date of birth Write here… Address Write here… Telephone Write here… This is how I tell people how I feel Write here… Family contact Write here… Relationship Write here… Address Write here… Telephone My support needs and who gives me the most support Write here… Write here… My carer speaks Page 2

3. Things you must know about me Completed by Date Review date Write here… Religion Write here… Religious needs Write here… Ethnicity Write here… Doctor (GP) Write here… Address Write here… Telephone Write here… Other services and professionals involved with me Write here… Allergies Write here… Risk of choking when eating, drinking or swallowing Page 3

4. Things you must know about me Completed by Date Review date My heart or breathing problems Write here… Medical interventions (how to take my blood, blood pressure, give injections) Write here… My current medication Write here… Page 4

5. Things you must know about me Completed by Date Review date Operations and illnesses I have had Write here… What to do if I am worried or upset Write here… Page 5

6. Completed by Date Review date Things that are important to me How to communicate with me (such as speaking, signing, pictures) Write here… How I take medication (such as tablets, injections, syrup) Write here… How to tell if I am in pain Write here… Page 6

7. Completed by Date Review date Things that are important to me Problems with my sight and hearing Write here… How I move around (such as walking aids, posture in bed) Write here… My personal care (such as dressing, washing) Write here… How I use the toilet (such as continence aids, help to get to the toilet) Write here… Page 7

8. Completed by Date Review date Things that are important to me How I eat (such as needing food cut up, risk of choking, help with eating) Write here… How I drink (such as small amounts, thickened fluids) Write here… How I sleep (such as sleep patterns, routines) Write here… What support is best for me (keeping me safe) Write here… Page 8

9. Please do these things Completed by Date Review date My likes and dislikes Things I like Like what makes me happy, things I like to do such as watching TV, reading, music and my routines Things I don't likeLike shouting, some kinds of food and being touched. Things I like Things I don't like Don't do these things Write here… Write here… Page 9

10. Notes Write here… This Hospital Passport is based on original work by Gloucester Partnership NHS Trust, Wandsworth Community Disability Team and Wandsworth Council. Page 10