Reasonable Adjustments Form

Health and Care organisations must make reasonable changes to their services so they can be accessible to people with disabilities. This includes people with a Physical, sensory, learning, or mental disability, including Dementia and Autism.

We are actively reviewing our processes and have created a more robust process for identifying and recording Reasonable Adjustments.

Please see the online questionnaire and consent form to tell us about any Reasonable Adjustments you may have.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Condition/ Disability/ Significant impairment to which this reasonable adjustment request relates to

    Does lip read (optional)
    Uses British Sign Language (optional)
    Uses deaf blind intervenor (optional)
    Uses electronic note take (optional)
    Uses lip speaker (optional)
    Uses Makaton (optional)
    Uses manual note taker (optional)
    Uses personal audio device to record information (optional)
    Uses speech-to-text reporter (optional)
    Uses telecommunication device for the deaf (optional)
    Uses functional communication skills (body language) (optional)
    Uses gestures for communication (optional)
    Uses non-verbal communication (optional)
    Uses objects for communication (optional)
    Uses photographs for communication (optional)
    Uses symbols for communication (optional)
    Uses verbal communication (optional)
    Uses voice-aid to support communication (optional)
    BSL interpreter needed (optional)
    Hands-on signing interpreter needed Optional (optional)
    Makaton sign language interpreter needed (optional)
    Needs an advocate (optional)
    Requires deaf blind block alphabet interpreter (optional)
    Requires deaf blind communicator guide (optional)
    Requires deaf blind haptic interpreter (optional)
    Requires deaf blind manual alphabet interpreter (optional)
    Requires lip speaker (lip reading) (optional)
    Requires manual note taker (optional)
    Requires sighted guide (optional)
    Requires speech-to-text reporter (optional)
    Sign-supported English interpreter needed (optional)
    Visual frame sign language interpreter needed (optional)
    Requires contact by email (optional)
    Requires contact by letter (optional)
    Requires contact by short message service text message (SMS) (optional)
    Requires contact by telephone (optional)
    Requires contact by text relay (optional)
    Requires contact via carer (optional)
    Requires information by email (optional)
    Requires information in contacted grade 2 braille (optional)
    Requires information in easy read (optional)
    Requires information in Makaton (optional)
    Requires information in un-contracted grade 1 braille (optional)
    Requires information verbally (optional)
    Requires 3rd party to read out information (optional)
    Difficulty analysing information (optional)
    Uses apps on mobile device to support communication (optional)
    Difficulty processing information at normal speed (optional)
    Needs assistance with communication (optional)
    Requires appointment reminders (optional)
    Has my health care passport (hospital passport) (optional)
    Expresses pain atypically (optional)
    Requires carers to be present at encounters (optional)
    Has appointed person with personal welfare LPA (optional)
    Requires constant supervision (optional)
    Unsafe to be left alone (optional)
    Care to be delivered in consultation with the patients carers (optional)
    Preference for male health care professional (optional)
    Preference for female health care professional (optional)
    Needle phobia (optional)
    Dependence on seeing eye dog (optional)
    Requires priority appointment (optional)
    Requires extended appointment (optional)
    Patient requires minimal waiting time between arrival and being seen (optional)
    Requires first appointment (optional)
    Requires last appointment (optional)
    Requires home visits where possible (optional)
    Requires distraction for any procedure (optional)
    Requires familiarisation for procedures (optional)
    Requires familiarisation with environment of care (optional)
    Has anxiety related to clinical settings (optional)
    Noise intolerance (optional)
    Photophobia (optional)
    Eyes sensitive to light (optional)
    Requires wheelchair access (optional)
    Requires low-light environment (optional)
    Requires single room during inpatient care (optional)
    If the patient doesn’t have capacity, is it being done in the persons best interests? (optional)
    Does use a communication device (please specify) (optional)
    Does use a hearing aid (optional)
    Preferred method of communication written (optional)
    Uses a citizen advocate (optional)
    Uses a legal advocate (optional)
    Requires reasonable adjustments for health and care access (Equality Act 2010 (optional)
    Are you happy for this to be shared with other organisations in the NHS?
    Does the patient consent to their reasonable adjustments being recorded in this way?

  • Best Interest Decision

    Please fill out the below if applying on behalf of another patient

    Lasting power of attorney for health and welfare (optional)
    Deputy (optional)
    Parent (optional)
    Legal guardian (optional)
    Independent advocate (optional)
    Are you happy for this to be shared with other organisations in the NHS and social care that will be involved in your care (National Care Records Service)?
    I consent this information to be shared
The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.
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Page last reviewed: 31 July 2026
Page created: 05 November 2026