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5 Medical and personal information

Medical and personal information forms an important basis for the functional assessment. The information may be used both as preparation and as a structured checklist in the assessment process. 
All handling of personal data must take place in accordance with current data protection legislation (GDPR). Information must be stored securely, and it is recommended that a case number be used rather than a name where possible. 

5.1 Consent 

Collection of medical and personal information presupposes informed consent from the person themself or from a legal guardian. The same applies to the use and storage of audio and video recordings. The assessor is responsible for familiarising themself with the applicable regulations in their own country before the assessment is carried out. 

5.2 Case information

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? 
  • Collection of medical information 
  • Making video and audio recordings in connection with the assessment process 
  • Storage of video and audio recordings 
Tick applicable consents:
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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) 


5.3 Medical information 

5.3.1 Diagnostics 

Medical diagnoses and their functional consequences are described here (for example, in strabismus (squint), the visual field is narrowed and the ability to see stereoscopically is affected, which often leads to motor uncertainty and clumsiness). 
For each diagnosis, it may be useful to make a note of the following: 
  • Is the diagnosis based on clinical findings or genetic tests? 
  • When was the diagnosis made? 
  • Who made the diagnosis? 
Note: Medical records should contain the most recent information. If updated or new examinations are needed, these should be carried out. The discharge summary should be from the examining doctor (containing a brief description of the conclusions from the examination, any treatment, and who is responsible for the further course of treatment. This may also be a neurologist, physiotherapist, occupational therapist or other specialist). 
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?) 
 


5.4 Indicators for observation – guiding structure 

When assessing whether the indicators for observation are present, partly present, not present or not relevant, the following guidelines are used: 
  • Present: When you can observe the behaviour associated with the indicator for observation. Here the behaviour is judged to be consistent and continuous and not determined by the individual context in which the user is situated. 
  • Partly present: When you can to some extent observe the behaviour in relation to the indicator for observation. This means that the behaviour is situation-dependent and may be observed sometimes and to a certain extent. In this case, the environment must be arranged in such a way that the behaviour becomes visible. 
  • Not present: When you cannot observe any of the behaviours associated with the indicator for observation. 
  • Not relevant (N/A: Not Applicable): When the indicator for observation does not apply because of individual factors such as physical limitations or other more situation-dependent factors (for example, if a person is deaf, observation indicators concerning listening skills will be scored as not relevant (N/A)). 

5.4.1 Communication and interaction 

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 
  
 
 

Observation form Communication and interaction

Pre observation - Green
Post observation - Red
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

5.4.2 Acquisition of information 

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 
 
 
 

Observation form: Information acquisition

Pre observation - Green
Post observation - Red
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

5.4.3 Orientation and independent mobility 

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 
 

Observation form: Orientation and free movement

Pre observation - Green
Post observation - Red
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
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