AAC Adult Case History Form

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Transcription:

AAC Adult Case History Form Name: Date: Date-of-birth: Age: Address: Phone: Alternate Phone: Home Work Cell (CIRCLE ONE) Home Work Cell (CIRCLE ONE) Email Address: Occupation/former occupation: Employer: Highest Level of Education Completed: Name of Spouse or Nearest Relative: Native Language: Primary Language: Physician s name: Phone: Referred by: Person completing this form: Relationship: A. MEDICAL HISTORY 1. What is your primary disability? 2. Is your disability the result of a recent accident or illness? If so, please explain. Do you have any medical conditions which have affected your ability to communicate? If yes, please indicate the type of condition.

3. Are you presently taking any medication? If so, please list and indicate reason for taking them. 4. Describe any pertinent surgery you have had. Indicate year of the surgery. 5. Have you ever had any of the following? Please check all that apply: Influenza Stroke Seizures Pneumonia Meningitis Encephalitis Heart Disease Weakness of arms or legs Uncontrollable trembling Difficulty swallowing Shortness of breath Measles Allergies Sinus problems Frequent colds Thyroid problems Other (please describe): B. VISION STATUS No visual impairment Visual impairment 2. Date of most recent vision exam: 3. Results: 4. Do you wear glasses or contacts? If so, for what purposes?

C. HEARING STATUS No hearing loss Hearing loss 2. Date of most recent hearing exam: 3. Results: 4. Do you wear a hearing aid? 5. Do you use sign language? D. MOTOR STATUS No motor loss Motor impairment (If yes, please answer below) 2. Are you ambulatory? 3. Do you require any special equipment for mobility purposes? 4. Please describe the nature of your physical impairment. 5. Please describe paralysis or paresis, if any exists. E. COMMUNICATION STATUS 1. Why do you wish to be evaluated at our clinic? 2. How do you communicate most of the time? (Check any appropriate boxes) Speech Manual signs (ex. pointing, gesturing, etc.) Photographs/pictures Communication board Electronic communication device (pleasespecify): Sign Language Other

3. If you have communicated by means other than speech in the past (ex. gesturing, devices, etc ), please describe your successes or failures using them. 4. Check the appropriate column as it applies to you now: CAN CAN T Indicate meaning by gesture Repeat words spoken by others Use one or a few words over & over Use swear words often Use some words spontaneously Say short phrases Say short sentences Follow requests Understand directions Follow radio or TV speech Read signs with understanding Read newspapers, magazines Tell time Write name without assistance Write sentences, letters Do simple arithmetic Handle money and make change F. PERSONAL INFORMATION 1. What is your occupation/former occupation? 2. What is your highest level of education? 3. Please describe your involvement in activities (i.e., church, sports, hobbies ). 4. Please describe your typical daily activities and in what settings (home, work, etc.) they occur. 5. Have your communication difficulties since the injury changed your life? If so, how?

6. Are there times of day or situations in which your communication is better? Worse? Please explain. 7. How do others react to your communication? 8. Please list those family and friends with whom you regularly interact with. 9. Would you be willing to use a communication board or device if recommended? Why or why not? 10. Will significant others be participating in this evaluation? If so, who? 11. Are significant others willing to learn and use a non-speech communication system? 12. If recommended for a device, how would you fund the device? 13. Are there any concerns you would like to discuss regarding your communication?

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