Sensory-Friendly Program at Inova Loudoun ER: Parental Intake Form

Patient Information

Thank you for choosing the Children's Emergency Room at Inova Loudoun Hospital to care for your child. Please fill out this form to help us learn how to best meet the needs of your child.

Questions? Call us at 703-858-6048

Patient First Name

Patient Last Name

Developmental/Cognitive Level

Communication Style

Communication Devices

Best way to approach your child?

Signs of distress

Signs of pain

Calming strategies used at home

Ability to transition to new environments

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