My Hospital Passport
This passport belongs to:
The Hospital Passport contains information that children, young people and their families want to share about their care and support needs, to promote a positive hospital experience.
The Hospital Passport:
Is not a medical record completed by patient, family or caregiver contain as much, or information as the wants to share to the patient, and home with them.
Hello my
name is:
Stick
a photo of yourself in the
frame,
or draw yourself.
I like to
be
called: Ko au tēnei
All About Me
My NHI number: My Date of birth: My Address: My phone number: My Parents / carer names: My Family / whānau: Languages I understand / speak:
How I communicate and express my needs:
My religious / spiritual / cultural needs:
My allergies (if any):
My health condition:
Who else do I see in the hospital?
I also want you to know:
Important Things
How to communicate with me:
Things that help me settle:
Things that make me anxious:
will know I am in pain, anxious, hungry or tired if:
I am sensitive to:
Things I like, and am interested in:
Things I need help with:
My hospital visit would be more comfortable if:
Things I also want you to know:
My Treatment
How I like my treatment: How I take my medication: Things that help with treatment, procedures:
People who support me: I also want you to know: Date:
What I need to bring to hospital • Travel form • Equipment • Feeding tubes • Special formula/food • Special toy • Medications • Other:
Notes:
southernhealth.nz contactus@southerndhb.govt.nz Children’s Ward, Southland Hospital Phone:(03) 2181949 NZ bird illustrations: @tinykiwi