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Patient Summary for person with Developmental Disability


Responding to county board concerns that some people with developmental disabilities may have to enter a hospital/emergency room without the assistance of their direct support professional or family member due to COVID-19 protocols, OACB has created a one-page (front/back) document that can be completed by a provider, county board, or family member to share key health information with medical professionals.

This "health passport," created by OACB staff with the input of Dr. Susan Abend of the Right Care Now Project, includes space for basic information about the person, their health status/medical history, and aspects of their developmental disability that would be important for medical professionals to know when considering treatment. This information includes:

  • Name and Emergency Contact Information;
  • COVID-19 Symptoms and Risk Factors;
  • Basic Medical History, Medications, and Allergies;
  • Disability-Related Personal Assistance Needs;
  • Communication Preferences, Likes, and Dislikes; and
  • Do Not Resuscitate/Living Will Declarations.

This form is intended as a resource only and is not legally required by the State of Ohio or any local public health agency. County boards should feel free to share this form with anyone as they see fit. It can be completed electronically or printed and distributed as paper copies for provider staff to complete by hand.

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