Sensory-Friendly Program at Inova Loudoun ER: Parental Intake Form

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Thank you for choosing the Children's Emergency Room at Inova Loudoun Hospital to care for your child. Please fill out this form to help us learn how to best meet the needs of your child.


Questions? Call us at 703-858-6048

Patient Information

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Patient First Name
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Patient Last Name
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Patient Date of Birth (MM/DD/YYYY)
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Developmental/Cognitive Level
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Communication Style
Communication Devices
Best way to approach your child?
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Signs of distress
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Signs of pain
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Calming strategies used at home
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Ability to transition to new environments

Motivators/Likes

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Food/Drink
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Activities
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Objects/Toys
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Environment

Stressors/Dislikes

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Food/Drink
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Activities
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Objects/Toys
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Environment

Sensory Challenges

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Smell (indicate sensitive or seeking and describe)
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Touch (indicate sensitive or seeking and describe)
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Sight (indicate sensitive or seeking and describe)
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Noise (indicate sensitive or seeking and describe)
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Crowds (indicate sensitive or seeking and describe)
If applicable: Other sensory challenges (indicate sensitive or seeking and describe)

Previous Medical Experience

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Previous procedure experiences (IV's, blood work, x-rays, exams, injections, etc.)
What helped to make the procedure easier for your child?
What could have been done differently to help your child cope better?
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Has your child ever needed sedation for a medical procedure or dental work?
If yes, how did they respond?
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How does your child prefer to take medications at home?
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Procedure preferences (in the event your child needs an IV, blood draw, or other tests)
Other
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During procedure
Other
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