Patient Name: ____________________________ Chart Number:_____________ DOB ____/____/____ Male ______ Female ______ Phone Number: ________________ Provider: _____________________ EDUCATIONAL NEEDS ASSESSMENT Ability to Read: Illiterate Limited Adequate Barriers to Learning: None Chronic Pain Speech Langauge Cognitive/Memory Vision Impaired/Blind Hearing Impaired/Deaf Dexterity Emotional Ambulation Limitation: Yes No (Cane, Walker, Wheelchair) Financial Constraints: Yes No (Notify Social Services) Are there cultural/religious practices that may affect patient’s healthcare? No or explain: _____________________________________ _____________________________________ Level of Education Completed: ____________ Comprehension Ability: High Medium Low Preferred Learning Method: Auditory Visual Written Demonstration Include in Teaching: Patient Significant Other (SO) Name : ____________________ Relationship: _______________ Time Available: ______________ ADDRESS AS NEEDED: Medication (Dose. Frequency), Missed Dose, When to Notify MD Food/Drug Interaction Community Resources Diet Rehabilitation Equipment Staff Signature/Title: ____________________________________________ Date: __________________________ Rc/rp 3/1/07 Readiness to Learn: (RTL) 1. Eager 5. Ask Questions 2. Acceptance 6. Misses Appt. 3. Nonacceptance 4. Refuses Teaching Method Code: (TMC) A= Audivisual H=Handout E= Explanation G=Group Class D=Demonstration I=Individual O-Other: __________________________ Response Code: (RC) 1. Verbalized Informed Consent 2. Return Demonstration Perfomred 3. Requires Additional Instruction 4. Unable to Teach: (Comment Below) Date Start and End Times R T L Learning Need/Consent Learner PT. /SO T M C R C Comments/ Signature (List Teaching Materials Given)