ACT Website Form

* Parent/Guardian First Name and Last Name

* Email

Parent/Guardian Phone number

* Patient's Name

Patient Birthdate

How would you describe your child's past healthcare experiences?

Has your child had any visits that were very upsetting or hard for them? What made the visit(s) upsetting or hard?

Has your child had any visits that went well? What made the visit(s) successful and positive?

How would you rate your stress when bringing your child to the doctor's office or hospital on a scale of 0 to 5? (0 indicates no stress, 5 indicates a lot of stress)

0

1

2

3

4

5

How upset or anxious does your child get at the doctor, dentist, or hospital on scale of 0 to 5? (0 indicates no upset, 5 indicates a lot of upset)

0

1

2

3

4

5

Which clinics/hospital areas are difficult for your child?

All areas

All inpatient

All outpatient

Concourse

DDBP

Dental

EEG

Emergency Department

Endocrinology

ENT

GI

Inpatient stays

Ophthalmology

OT/PT

Parking garage

Primary Care

Radiology

Riding the elevator

Same Day Surgery

Sleep Study

Test Referral Center (Lab)

Urology

Additional difficult clinics/hospital areas

Does your child become overwhelmed/overstimulated in the waiting room?

Yes

No

Does your child have difficulties with waiting?

Yes

No

Is it difficult for your child to enter or transition into the hospital environment?

Yes

No

* Please specify which areas

Does your child have difficulty leaving the hospital/clinic space?

Yes

No

Are there certain areas of the hospital to avoid? Examples: Cafeteria, gift shop, elevators, parking garage, etc?

What is the best way for us to examine your child?

Allow time for breaks

Allow to touch any equipment themselves

Do parts of exam on someone else first

Engage them in distraction

Let them sit where they're comfortable

Taking breaks in exam with counting

Tell what they're doing before each step

Other examination preferences

What parts of exams and procedures does your child have difficulty cooperating with?

All are difficult

All vitals (height, weight, blood pressure, pulse, etc.)

Anesthesia mask

Checking blood pressure

Checking reflexes

Ear exam

Eye exam

Head measurement

Height

IV

Listening to heart/lungs

Looking in mouth/throat

Lying down

Oxygen mask/Nasal cannula

Procedures with needles (e.g. blood tests, shots, etc.)

Removing bandages

Sitting on the exam table/chair

Touching/feeling parts of the body for exam

Weight

Additional examination concerns

Will your child wear a hospital gown?

Yes

No

Will your child wear a hospital ID band on their wrist or ankle?

Yes

No

How does your child tell you what they want/need?

AAC/speech generated device

ASL or sign language

Conversational

Guiding or leading by the hand

Is non-speaking

Letter board (RPM)

Making sounds

Picture Exchanged Communication System (PECS)

Pointing/gesturing

Single words/phrases

Vocalizations

Other communication methods

How much do you think your child understands about his/her visit on a scale from 1 to 5? (0 indicates no understanding, 5 indicates understands everything)

0

1

2

3

4

5

How can we best tell your child what to expect?

1-2 step instruction

ASL or sign language

Demonstration or modeling

First/Then board

Handwritten words

Pictures or symbols

Single-step instruction

Single words

Social story/narrative

Unsure

Verbally at age-appropriate level

Visual schedule

Other Learning Methods

What is the best way to prepare your child for transitions?

A wheelchair, stroller or wagon

Counting aloud

No preparation needed

Using a clock or watch

Using a timer

Using a visual schedule

Verbal prompting

How do you know when your child is experiencing pain?

Changes in behavior

Changes in breathing

Change in eating/drinking

Changes in play or activity

Crying

Decreased frustration tolerance

Facial expressions

Gets quiet/Shuts down

Guarding parts of body

High pain tolerance

Hurting others

Hurting self/Self-injury

Increase in sleep

Pointing/Gesturing

Pointing/Touching area

Shaking/Rocking

Unsure when in pain

Verbalizes their pain

Is your child sensitive to

Bright lights

Crowds

Fragrances/smells

Loud noises

Pain

Small spaces

Sound of crying babies

Temperature Cold

Temperature Hot

Textures

Touch

Unexpected noises

Other sensitivities

If sensitive to touch, please specify (light, firm, all touch, specific body parts)

Does your child have any sensory difficulties related to any of the following medical supplies or equipment on their body

Band-aid

Blood pressure cuff

EEG leads

IV lines

NG-tube

Pulse oximeters

Sleep study leads

Sticky items (bandages, tape, etc.)

Tourniquet

Other sensory difficulties

Does your child enjoy sensory input including

Brushing/Scratching

Chewing/chewy

Deep pressure

Hugs

Jumping

Massage/Touch

Pacing

Smelling objects

Spinning

Vibration

Other sensory seeking activities

What are your child's stressors or triggers?

Bedrest

Being bored

Being in pain

Changes in routine

Divided attention

Environmental stressors (light, sound, colors, etc.)

Exams

Family/Caregiver departure

Lengthy appointments

Non-preferred demands

Not getting what they want

NPO status

Overstimulation

Procedure anxiety

Procedures with needles

Room confinement

Too many people in patient's personal space

Transition from car into building

Transitions

Unmet needs

Waiting

Waiting areas

Are there any words, phrases, or actions that will upset your child?

How will your child let us know if he/she is upset or anxious? Select all that apply.

AAC/speech device

ASL or Sign language

Attempting to escape

Crying

Cursing

Facial expressions

Physical motions (rocking, flapping, squeezing hands)

Pictures or symbols

Pictures with words

Pointing/gesturing

Property destruction

Screaming/Yelling

Throwing objects

Verbal aggression

Vocalizing

Does your child hurt others when upset?

Biting

Flailing

Grabbing

Head-butting

Hitting

Kicking

Pinching

Pulling hair

Scratching

Spitting

Throwing objects

Does your child hurt themselves when upset?

Biting-self

Cutting-self

Head-banging

Hitting

Kicking-self

Knee to head hitting

Pinching-self

Pulling their hair

Scratching-self

Other ways they may communicate being upset:

What comforts your child when he/she gets upset or anxious?

Books

Blanket

Bubbles

Calming sounds

Chewy tube

Conversation about favorite topic

Counting or singing

Deep breathing

Deep pressure

Food/Drink

Games

Give them some space

Give them some time

Headphones to decrease noise

Hugs

Light-up item

Limited talking

Low lighting

Music

Pacifier

Pacing or going for a walk

Papoose

Preferred Parent/Caregiver

Puzzle

Puzzles/Work task

Quiet space

Removal of trigger/stressor

Sensory ball

Showers

Soothing touch

Stuffed animal

Stuffed toy

Tablet

Tactile Fidgets

Talking to patient (casual conversation)

Videos

Weighted materials

Work task

What things may motivate your child to have positive behavior (e.g., favorite movies, characters, rewards, activities, etc.)?

How does your child adjust or respond to new setting, unfamiliar people, or change in routine?

Are there any strategies that you have found particularly helpful for anxiety producing situations in the past?

What are your child's strengths?

How would you describe your child and their personality?

Is there anything else we should know about your child?

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