Patient Information

       Is Texting Ok?  YesNo

Has the patient used AAC in the past or is currently using an AAC device?  YesNo

Academic History

Does the evaluation team/ training therapists have your permission to contact the school personnel to collaborate prior to the evaluation and schedule training sessions (if applicable) after the device is purchased?  YesNo

Fine Motor

Can the patient pick up and hold a cup?  YesNo

Can the patient pick up and hold a cookie?  YesNo

Can the patient pick up and hold a raisin?  YesNo

Can the patient point and press buttons on a cell phone/tablet?  YesNo

Does the patient typically throw things in frustration or anger?  YesNo

Communication

Does the patient try to communicate verbally?  YesNo

Does the patient show frustration because he/she is unable to communicate?  YesNo

Does the patient follow simple commands?  YesNo

Does the patient answer yes/no questions?  YesNo

Behavioral Concerns

Does the patient have a behavioral plan or need behavioral therapy?  YesNo

Functional Mobility

Does the patient walk independently?  YesNo

Does the patient use a wheelchair?  YesNo

Hearing and Vision

Does the patient have a hearing loss?  YesNo

Does the patient have any vision problems?  YesNo