Speech Evaluation – Technology Access Inc.

Speech Evaluation Form

I. Demographic Information

Patient Name:

Client Advocate:

Address:

Phone #:

DOB: Medicare/Medicaid ID#:

Secondary Diagnosis: ICD-9:

Onset:

Speech Language Pathologist Name: Phone #:

Address: Email Address

Date of Evaluation:

Physician Name and Address:

Phone #: Fax #

NPI# License #

II. Current Communication Impairment

A. General Statement of Patient’s condition-diagnosis: List medications, if applicable

__________________________________________________________________

1. Type of Communication impairment: Check all that applies Dysarthria

Aphasia

Apraxia

Aphonia

2. Severity of impairment: List impairment checked above with the corresponding severity. Mild

Mild-Moderate

Moderate

Moderate-Severe

Severe

3. Anticipated Course of Impairment: Check which applies No detectible Speech Disorder

Obvious Speech Disorder, intelligble

Reduction in speech intelligibly

Natural Speech supplemeted with SGD’s

No useful Speech (SGD only)

Loss of Speech

B. Comprehensive Assessment

1. Hearing Status

Does the patient possess the hearing ability to effectively use a SGD

to communicate functionally? Yes ________ No________

Does the client use a hearing aid? Yes_______ No________

2. Vision Status

Does the patient possess the visual ability to effectively use SGD to communicate effectively? Yes_______ No_______

Does the client wear prescribed eyeglasses? Yes_______ No________

3. Physical Status

Does the patient possess the physical ability to effectively use a SGD and required accessories to communicate? Yes _______ No _______ Comments

Motor Skills

Ambulatory Status

Direct Selection

Scanning

4. Language Skills

Linguistic Impairment Severity: Check which applies Mild

Mild-Moderate

Moderate

Moderate-Severe

Severe

Assessment tools/tests used in evaluation: Assessment test

Evaluation

Current communication ability: Check which applies Sign Language

Gestures

Pictures

Words

Writing/Spelling

Verbal Speech

1. Cognitive Ability

Impairment Level: Check which applies No Impairment

Mild Impairment

Moderate Impairment

Significant Impairment

Abilities with an SGD: Check which applies

Poor Fair Good Excellent

Memory

Attention

Problem Solving Skills

Comments

III. Daily Communication Needs

1. Specific Communication Needs:

a. Client interacts daily with: Check all that applies

Family __________

Caretaker __________

Health Care Professionals __________

Community __________

b. Clients needs: Check which applies

Request Emergency Aid ___________

Obtain Medical Care ___________

Advocate for him/herself __________

Express pain/reaction to medication __________

Express hunger/thirst __________

Express likes/dislikes __________

Additional Needs:

2. Ability to meet communication needs with Non-SGD treatment:

a. Speech Therapy

Date Began _____________ Date Ended:___________

Current Prognosis without a SGD: Check which applies

Poor ______

Fair ______

Good ______

Excellent ______

Future Prognosis without a SGD: Check which applies

Poor ______

Fair ______

Good ______

Excellent ______

b. Low Tech Strategies used during therapy sessions:

Results of Low Tech Strategies: Check which applies

Poor ______

Fair ______

Good ______

Excellent ______

Can the patients daily communication needs be met by low tech AAC or no-tech AAC technique?

Yes _______ No________

IV. Functional Communication Goals: Level of communicative independence the patient is expected to achieve outside the therapeutic environment with an SGD.

Check all that apply:

_____ Client will independently communicate physical needs and emotional status to immediate family/caretaker on daily basis, as needed.