PATCH Adaptive Care Plan Questionnaire

Please take a few minutes to answer each of the following questions to the best of your knowledge. While some questions may not seem relevant at this time, the answers will be helpful in completing a comprehensive Adaptive Care Plan for your child that can be used at future healthcare visits. A Child Life Specialist will be in touch with you to answer any questions you might have.

  • General Information

    Please tell us about your child.







  • MM slash DD slash YYYY

  • Past Healthcare Experiences

    Help us understand how your child responds to the healthcare environment by telling us about previous visits to the hospital or doctors’ offices and clinics.











































  • Communication

    Answers to the following questions will help us better understand how best to communicate with your child.




























  • If so, what do they mean?


















  • Healthcare Procedures

    So that we can minimize healthcare-related triggers, please answer the following questions to the best of your ability.






































  • 1) No sensitivity
    2) Sensitive, but does not affect behavior
    3) Behavioral trigger that stimulates a change in behavior or increased anxiety.




























































  • Please provide your contact information so that we may follow-up with you.






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