Patient Information Form printable pdf download

Patient Information Form

ALLINA INTERPRETER SERVICES

INFORMATION TO BE DOCUMENTED IN PATIENT’S CHART

To be filled out by interpreter and given to health care provider to be scanned into patient’s chart

INTERPRETER NAME:

AGENCY NAME:

DATE OF APPOINTMENT: ________________________________________________

INTERPRETATION START TIME WITH PROVIDER/NURSE TEAM

(does not include the time the interpreter arrived):

INTERPRETATION END TIME WITH PROVIDER/NURSE TEAM:

INTERPRETER CERTIFICATION (ASL): ____________________________________

LANGUAGE SPOKEN BY PATIENT: ________________________________________

PATIENT HAS LIMITED ENGLISH LANGUAGE PROFICIENCY ____Yes ____No

PATIENT IS DEAF OR HARD OF HEARING: ____Yes ____No

PATIENT IS DEAF AND BLIND: ____Yes ____No

INTERPRETED FOR (DOCTOR, NURSE, OTHERS): ________________________________

PLEASE PLACE PATIENT LABEL ON EDGE

OF LOWER RIGHT HAND CORNER OF FORM

Allina Health

Confidential

Updated 12/04/2012

Patient Information Form