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)