Filling in a Hospital Medical Form

CLB Level: CLB 3/Ph3
Essential Skills Focus:
Document Use
Reading
Task: Fill in a hospital medical form correctly
Purpose: Students will

Read a short story
Take important information from a short story and fill in a hospital medical form
Use their personal information to fill in a hospital medical form

Materials:
Short story (attached), a blank hospital form – 2 per student (one is attached). The hospital form was modified from the following website:
k/3mform.htm
Learning Style: Visual
Time: 75 minutes / Method:

Tell the class that this lesson will focus on filling in a hospital medical form. Previous lessons should have focused on some of the vocabulary that might appear on forms. Ask students to tell you some possible forms that they have had to fill in before. Listen and write some of these responses on the board. Possible answers could include – a job application form, an apartment lease, a student registration form, etc.

Provide students with the hospital medical form that they are to fill out (see attached). Before students fill in their own personal form, tell them that they will practice first by filling in a medical form for a fictional person who has had an accident and will be checking into the hospital – pencils only!

Pass out to students a short story (see attached) about a fictional person named Cindy who breaks her ankle. Have students read the story and then read it together as a whole class. After reading, tell students that they are to help Cindy by filling in her hospital medical form for her. Circulate and assist students as they work.

After students have completed their forms, correct them together as a whole class. Make an overhead of the blank form and have individual students come up and fill in parts of the form. This is now a good time to review some of the vocabulary that appears on this particular form (i.e. allergies, medication taken, etc.)

Debrief:

a) Language Component:
-What skill did you learn?
-What is Mrs. Wilson allergic to?
-Does Mrs. Wilson have a medical condition?
-Is Mrs. Wilson currently taking any medication?
-Who did Mrs. Wilson use as her emergency contact person?
b) Transfer
-Have you filled out a medical form at the hospital before?
-What kind of personal information did you need to fill in a medical form?
-What kind of medical information did you need to fill in a medical form?
-Where do you find your health registration number?
-Why do you think it’s important to have an emergency contact person?
-What other kinds of forms have you filled out before?
Follow Up:
Provide students with another blank hospital medical form. For homework students can fill in this form with their own personal information and hand it in the next class.

Information about an accident

This is Mrs. Cindy Ellen Wilson. She checked into the St. Boniface General Hospital in Winnipeg with a broken ankle. Mrs. Wilson broke her ankle while walking to work. She slipped on some ice on the sidewalk and fell. Mrs. Wilson was in a lot of pain. Mrs. Wilson’s neighbour called for an ambulance right away. The ambulance arrived in 10 minutes and took Mrs. Wilson to the nearest hospital. The nearest hospital was the St. Boniface General Hospital.

Mrs. Wilson currently lives at 103 Tache Street in Winnipeg. Her postal code is R7E 3G5. Her telephone number is 657-1642 and her e-mail address is . Mrs. Wilson was born in Berlin, Germany on April 6, 1971. She speaks English and German. German is her first language.

Mrs. Wilson has a peanut allergy. She cannot eat anything with peanuts, like peanut butter and some chocolate bars. She is not currently taking any medication but she does have asthma. Mrs. Wilson has had asthma since she was a little girl. Mrs. Wilson has a Manitoba Health Card. Her registration number is 364552.

Mrs. Wilson’s emergency contact person is her husband. They live at the same address. Mrs. Wilson has been married for 10 years. Her husband’s name is Ron T. Wilson. They have two children, one son and one daughter. Mr. Wilson is a delivery driver so he is not home a lot. The best way to contact him is by cell-phone. Mr. Wilson’s cell phone number is 269-3500.

Assignment: Fill out a hospital medical form for Mrs. Wilson

Medical Form

Check () the correct boxes 

Title:

Mr  Mrs  Miss  Ms  Dr  Other………………………

Family/Last name:…………………………………………………..

Given/First name:……………………………………………………

Initial of Middle Name:………………………………………………

Gender: Male  Female 

D.O.B.: Day  Month  Year 

Home address:…………………………………………………………………..

………………………………………………………………………………….

Postal code:……………………Phone/Tel.:…………………………………………

E-mail:………………………………………………………………

Country of birth:…………………………………………………………………

Language(s) spoken:……………………………………………………

MEDICAL HISTORY:

Allergies:………………………………………………………………………….

Medication:……………………………………………………………………….

Medical conditions:……………………………………………………………..

………………………………………………………………………………………

MB Health Reg. Number:…………………………………………………..

PERSON TO BE CONTACTED IN AN EMERGENCY:

Family/Last name:…………………………………………………..

Given/First name:……………………………………………………

Initial of middle name:………………………………………………….

Home address:…………………………………………………………………

………………………………………………………………………………….

Postal code:……………………Phone/Tel.:……………………………………...

Relationship:…………………………………………………………………….

WinnipegSchool Division Adult EAL ProgramEssential Skill Focus: Document Use

Author: Lucas SkeltonCLB level: CLB 3/Ph3