Case number: | |
State the person's living situation and status (student/worker/other): | |
The case has been referred by: | |
Contact history (when was the case referred?): | |
Name of associated doctor: | |
Who has been involved in the assessment? (the person themself / parents / guardians / relatives): | |
Has consent been obtained?
| Tick applicable consents: ◯ ◯ ◯ |
The following records/documents are available: | - Hearing – report, medical journal - Vision – report, medical journal - MRI examinations - Statements from a neuropsychologist - Any assessments, observations or other relevant observations from vision teachers, audiology teachers, deafblind consultants, physiotherapists, psychologists, etc., together with observations from familiar persons - Any medication and how it may affect the client’s functional ability - A brief status of the client’s life history and current situation (e.g. status plan) |
Main diagnosis (for example CHARGE, prematurity, etc.): | |
Other diagnoses: | |
Vision: | |
Has a medical visual diagnosis been established? (Yes / No / If yes, which?) | |
When was the last eye examination carried out by an ophthalmologist? | |
Visual acuity: | |
Optics: | |
Visual field: | |
Has a vision assessment been carried out by a vision consultant / teacher of the visually impaired? (Yes / No / If yes, which?) | |
Does the person use glasses, contact lenses or other visual aids (for example lighting, etc.)? (If yes, which? / If yes, to what extent are glasses used?) | □ Customized program in pc tablet, phone □ Optical aids □ Magnifying reading TV □ Reading machine □ Interpreter □ Other aids: |
Vision register – is the person registered? (applies in countries with a vision register) | |
Hearing: | |
Has a medical hearing diagnosis been established? (Yes / No / If yes, which?) | |
When and where was the last hearing test carried out? | |
What type of hearing test? (Audiological tests such as otoacoustic emissions (OAE), pure-tone audiometry, play audiometry, observational audiometry, ASSR (auditory steady-state response), ABR (auditory brainstem response), tympanometry, etc.) | |
Has the person had frequent middle-ear infections during childhood? | |
Does the person use hearing aids or hearing-technical aids? (for example, speech amplifier, etc.) (If yes, which? / If yes, how much are the hearing aids used?) | □ Hearing aid □ CI - one/two □ Amplifier □ Streamer □ Interpreter □ Other: |
Bodily-tactile sense; has the following been observed or identified: | |
Bodily-tactile sensitivity: Bodily-tactile sensitivity relates to the reaction that arises when someone is very sensitive to touch or to touching something. | |
Bodily-tactile selectivity: Bodily-tactile selectivity is used to describe variations in reactions when the person uses the tactile sense, for example that the person prefers or avoids different kinds of objects or substances/materials. | |
Birth history (premature birth, problems during pregnancy, etc.): | |
Sensory integration difficulties: The senses’ ability to receive information simultaneously and interact with one another. For example, using only one sense when directing attention towards something. | |
Is there any suspicion of: - Cortical Visual Impairment (CVI) - Auditory Processing Disorder (APD) | |
Does the person have motor challenges and/or balance problems? (yes / no / do not know; if yes, in what way?) | |
Is it known that the diagnosis causes sensory impairment in one of the two distance senses, with a possible progression in the other sense? (Yes / No / Do not know) | |
Is there a need for further examinations / assessments? (Yes / No / Do not know; if yes, which?) |
Communication and interaction | Present | Partly present | Not present | N/A | Comments |
HEARING | |||||
Does the person respond to sounds in the environment? | |||||
Can the person imitate sound? | |||||
Does the person respond to their name? | |||||
Does the person take part in turn-taking based on sound? | |||||
Does the person regulate their voice according to the situation? | |||||
Does the person participate in verbal conversations? | |||||
VISION | |||||
Can the person direct visual attention towards another person? | |||||
Can the person establish eye contact? | |||||
Does the person read facial expressions? | |||||
Can the person use vision in communication? | |||||
Can the person use vision to communicate with others at a distance? | |||||
Can the person use vision to shift attention between partner and an object of shared attention? | |||||
Can the person read communication in normal lighting? | |||||
BODILY-TACTILE | |||||
Does the person actively use the bodily-tactile sense to initiate contact with a partner? | |||||
Does the person actively use the bodily-tactile sense to follow others’ initiatives? | |||||
Does the person actively use the bodily-tactile sense to express themself? | |||||
Does the person actively use the bodily-tactile sense in turn-taking (listener and speaker positions)? | |||||
Does the person actively use the bodily-tactile sense to explore an object together with a partner while attention is also directed towards the partner? | |||||
Does the person actively use the bodily-tactile sense to engage in interaction and communication with several people? (multi-party conversations: overhearing, taking the initiative, listening) | |||||
NOTES / ASSESSMENT OF THE FUNCTIONAL INTERACTION BETWEEN THE SENSES | |||||
Communication and interaction | Hearing | Vision | Bodily-tactile | ||||||||||||||||
Observation point | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Partially present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Nor present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
N/A | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Information acquisition | Present | Partly present | Not present | N/A | Comments |
HEARING | |||||
Does the person respond to sounds in the environment? | |||||
Does the person actively relate to distant sounds? | |||||
Can the person recognise familiar persons by means of hearing? | |||||
Does the person recognise sounds regarded as familiar? | |||||
Does the person direct auditory attention towards a person who is speaking? | |||||
VISION | |||||
When sitting still, does the person respond to visual stimuli in the visual field? | |||||
Does the person visually orient towards different objects when these are placed in front of them? | |||||
Does the person recognise objects and/or people when they are not moving? | |||||
Can the person use gaze to follow objects/people without moving the head? | |||||
Does the person recognise faces using vision? | |||||
Does the person act on the basis of visual information that is provided? | |||||
Does the person read information from pictures (2D)? | |||||
Does the person recognise visual details within a whole? | |||||
Can the person construct a whole from visual details? | |||||
Does the person respond equally well to weak and strong colours? | |||||
Are vision and hands used at the same time when the person is to grasp an object? | |||||
BODILY-TACTILE | |||||
Does the person actively use the bodily-tactile sense to direct attention towards objects and/or people in the environment? | |||||
Does the person actively use the bodily-tactile sense to explore an object systematically? | |||||
Does the person actively use the bodily-tactile sense to identify similarities and differences between objects? | |||||
Does the person actively use the bodily-tactile sense to obtain information about how two or more objects are positioned in relation to one another? | |||||
Does the person use the bodily-tactile sense actively to explore other people? | |||||
Does the person actively use the bodily-tactile sense to perceive other people’s bodily expressions, emotions and reactions? | |||||
Does the person direct bodily-tactile attention towards other people’s touch on their own body? | |||||
NOTES / ASSESSMENT OF THE FUNCTIONAL INTERACTION BETWEEN THE SENSES | |||||
Information acquisition | Hearing | Vision | Bodily-tactile | ||||||||||||||||||||
Observation point | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Partially present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Not present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
N/A | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Orientation and independent mobility | Present | Partly present | Not present | N/A | Notes |
HEARING | |||||
Does the person recognise the environment through hearing? | |||||
Can the person use hearing to move in different directions? | |||||
Does the person orient in relation to sound sources in the nearby environment? | |||||
Does the person orient by sound at a distance? | |||||
Does the person explore the environment by means of voice and hearing? | |||||
Does the person orient by means of echolocation? | |||||
VISION | |||||
Can the person use vision to orient in the environment? | |||||
Does the person orient from one point to another solely by means of vision? | |||||
Does the person navigate around obstacles by means of vision? | |||||
Does the person use vision to become aware of changes in level? | |||||
Can the person move under different lighting conditions? | |||||
Can the person orient without discomfort from different light sources? | |||||
Can the person orient in darkness by means of vision? | |||||
BODILY-TACTILE | |||||
Does the person actively use the bodily-tactile sense to locate landmarks in the environment? | |||||
Does the person actively use the bodily-tactile sense to navigate in the environment? | |||||
Does the person actively use the bodily-tactile sense to recognise different rooms and/or environments? | |||||
NOTES / ASSESSMENT OF THE FUNCTIONAL INTERACTION BETWEEN THE SENSES | |||||
Orientation and free movement | Hearing | Vision | Bodily-tactile | |||||||||||||
Observation point | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Partially present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
Not present | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |
N/A | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ | ☐ |