Language & Communication

 ☐ I prefer to speak in: _________________________

 ☐ I would like a medical interpreter.

 ☐ I need written materials in: ___________________

 ☐ Please speak slowly or use simple explanations.

Spiritual or Religious Beliefs

 ☐ I follow a specific religion or spiritual practice: ___________________

 ☐ I need time or space for prayer/rituals.

 ☐ I avoid certain foods or medicines due to religious reasons.

 ☐ I may decline blood transfusions or certain procedures for religious reasons.

Diet & Food Preferences

 ☐ I follow a specific diet (e.g., vegetarian, halal, kosher, diabetic):

______________

 ☐ I fast or have dietary restrictions during religious periods (e.g., Ramadan,

Lent).

 ☐ I have food allergies or sensitivities:

_________________________________

Family, Gender, and Social Needs

 ☐ I prefer to have a family member involved in medical decisions.

 ☐ I would like to speak with a provider of a specific gender, if possible.

 ☐ In my culture, modesty is very important—please let me know if I’ll need to

change clothing or be examined.

☐ I need help understanding how my insurance, immigration status, or financial

situation may affect care.

Traditional or Cultural Healing Practices

 ☐ I use traditional remedies, herbal medicines, or spiritual healing.

 ☐ I want to talk about how these can work with my medical treatment.

Anything Else You’d Like Your Team to Know?

Tips for Patients

 Bring this list with you to appointments or hospital admissions.

 Don’t be afraid to speak up. Your care should reflect who you are.

 Ask your care team if you can include a cultural liaison, spiritual advisor, or

family representative.

Remember: You Are the Expert of Your Own Life.

Your beliefs, background, and identity are not barriers—they’re part of your healing journey.