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8 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.

8.1 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.

8.2 Case information

Case number:
State the person’s living situation and daily occupation:
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 the 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)

8.3 Medical information

8.3.1 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 – one / two □ CI – one / two □ Conversation 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?)