How does the person themself (and, if relevant, familiar persons if they have been interviewed) experience how vision functions? | |
Is there anything the person can see in some situations, but not in others? (e.g. in darkness, with glare, in visually cluttered environments) | |
Preconditions that may affect the visual assessment? Day-to-day condition, energy level, etc. |
How does the person themself (and, if relevant, familiar persons if they have been interviewed) experience how hearing functions? | |
The person’s awareness of their own voice (knowing when they speak too loudly or too softly, etc.) | |
Preconditions that may affect the hearing assessment? Day-to-day condition, energy level, etc. |
How does the person themself (and, if relevant, familiar persons if they have been interviewed) experience the functional use of the bodily-tactile sense? | |
To what extent is the person aware of the use of their own bodily-tactile sense (based on experience)? | |
Does the person have technical aids for tactile support? If yes, how often are these in use? | □ Braille display together with PC, tablet or telephone □ Interpreter □ Other |
Are there any specific preconditions that may affect the assessment of the bodily-tactile sense in the person being assessed? Day-to-day condition, energy level, etc. |
Which form of communication do you use? | □ Sign language □ Spoken language □ Tactile forms of communication □ Do you use several forms of communication in combination with each other? |
Do you use several forms of communication in combination with each other? | If yes, please describe: |
In one-to-one conversations, which communication method(s) do you prefer? | |
Can you follow a one-to-one conversation without difficulty? | |
Which conditions are necessary for you to hold a conversation with one person? (familiar person, familiar dialect, familiar topic, sound and lighting conditions, positioning, adaptations, aids) | |
In conversation with several people, which communication method(s) do you prefer? | |
Which conditions are necessary for you to hold a conversation with several people? (number of participants, sound and lighting conditions, positioning, adaptations, aids) | |
Can you follow a conversation in groups of 3–4 people without difficulty? | |
Which forms of distance communication do you prefer? | □ Email □ SMS □ Post □ Phone □ Social media □ Other media □ Other: |
Under which conditions, for example aids/adaptations, can you use these forms of distance communication? | |
Are there any matters a conversation partner needs to consider in communication? | □ Turntaking □ Feedback □ Chance of theme □ Attention to detail □ Other: |
Do you experience challenges in communicating with other people because of your sensory loss? |
How does vision affect your ability to communicate? | |
Can you use your vision for the following communicative activities: | |
Read sign language? | If yes, at what distance does this work best? |
Lip reading? | If yes, at what distance does this work best? |
Read facial expressions? | If yes, at what distance does this work best? |
Distinguish between faces to identify the speaker? | If you cannot see the speaker’s face, are you still able to understand what is being said? |
Communicating with several people simultaneously? | |
Using video calls? | |
Perceiving when changes occur in conversation or if the topic shifts? | |
Do you use vision for turn-taking in conversations? | |
Can you easily shift focus between several people, or between a person and an object in conversation? | |
Can you communicate and read body language and facial expressions in a normally lit room? | |
Are you able to maintain eye contact with other people? | |
How does hearing affect your ability to communicate? | |
Can you use your hearing in the following communicative activities? | |
Perceiving spoken language? | If yes, what works best: high-pitched or low-pitched voices? |
At what distance do you hear best? | |
Are you able to distinguish between and understand dialects? | |
Do you perceive when it is your turn to speak in a conversation (turn-taking)? | |
Do you notice nuances in voice, such as irony, humour, changes in mood, etc.? | |
Can you participate in communication with several people at the same time? | |
Can you communicate by telephone? | |
Can you imitate sounds that you hear? | |
When you hear something, do you confirm this? | |
Do you perceive when someone addresses you by name? | |
Are you able to sustain the same level of focus over time in conversations involving sound? | |
Are you able, through hearing, to regulate your voice so that it is adapted to the situation? | |
How does the bodily-tactile sense affect your ability to communicate? | |
Do you use your tactile sense in the following communicative activities: | |
To read sign language? | If yes, as the primary modality? |
Use of haptic communication? | |
As support for vision and/or hearing? | |
Perceiving topic changes in tactile conversations? | |
Perceiving nuances such as humour, irony, etc.? | |
Taking part in multi-party conversations? (moving between several conversation partners in the same conversation) | |
Do you use your tactile sense to reach out and contact others? | |
Can you perceive others’ initiatives through the tactile sense? | |
Do you actively include the tactile sense in conversations, both when listening and when speaking? | |
Which information channels do you prefer to use? | □ Radio □ Newspapers □ TV □ Audio newspaper □ Internet-based □ Braille newspaper □ Other: |
Which aids or other adaptations do you need in order to use these channels of information? | |
Which aids/services do you use for safety and alerting? | Are they: □ Auditive? □ Visual? □ Tactile? □ Combinations? |
How do you obtain information about society, the local community, descriptions of surroundings, etc.? | □ Interpreter/guide □ Personal assistant □ Support contact □ Reading and secretarial help □ Other, describe: |
How does vision affect your ability to gather information from the environment? | |
Can you use vision to do the following activities? | □ Watch television? □ Reading? □ Find information on the internet? □ Perceive information in your surroundings, such as finding your way/orientate in familiar and unfamiliar surroundings? |
When you are sitting still, do you respond to visual impressions in your surroundings? | |
Do you look at different objects/items when they are placed in front of you? | |
Can you recognise people or objects when they are stationary (not moving)? | |
Do you use vision to obtain an overview by following movement in your surroundings? | |
Do you recognise faces solely by means of vision? | |
Are you able to read information conveyed through pictures (2D)? | |
Do you recognise visual details within a whole? | |
On the basis of visual details, are you able to assemble them into a whole? | |
What do you perceive best – weak or strong colours? |
How does hearing affect your ability to gather information from the environment? | |
Can you use your hearing for the following activities? | □ Listen to the radio? □ Listen to music? □ Attend a lecture/course? |
Do you hear the doorbell and the phone? | |
Do you respond to sounds in the environment? | |
Do you perceive sounds coming from a distance? | |
Can you recognise people close to you solely by means of hearing? | |
When you hear a sound, are you able to identify what the sound is and whether you have heard it before? | |
When someone is speaking, are you able to attend to what is being said and to the person speaking? |
How does the bodily-tactile sense affect your ability to gather information from the environment? | |
Can you use the tactile sense for the following activities? | □ Read written material? □ Get information via tactile schedules/calendars and more? □ Get an overview of your immediate surroundings? |
Do you actively use the tactile sense to direct attention towards objects and people in your surroundings? | |
Do you actively use the tactile sense to explore objects? | |
Do you actively use the tactile sense to identify similarities and differences between objects? | |
Do you actively use the tactile sense to understand spatial relations between objects and places? | |
Do you actively use the tactile sense to explore other people? | |
Do you actively use the tactile sense to perceive other people’s bodily expressions and reactions? | |
Do you actively use the tactile sense to become aware of other people’s touch on your own body? |
Which sense do you rely on primarily for orientation and movement? | □ Visual □ Auditive □ Tactile □ Combination of several senses, describe: |
What kinds of adaptation do you need? | □ Lighting □ Landmarks / reference points (visual, tactile, auditory) |
Do you use a white cane, guide dog or guide? | |
Can you find your way indoors in unfamiliar places | □ without a guide □ with a guide |
Can you find your way outdoors in unfamiliar places | □ without a guide □ with a guide |
Do you use public transport and, if so, under what conditions? | |
How do you travel to and from activities within and outside the home? |
How does vision affect your ability to orient in the environment? | |
How do you use vision when walking in unfamiliar terrain? | |
How do you use vision when walking in familiar terrain? | |
Can you use vision to perceive obstacles in the environment? | |
Can you use vision to obtain information about the surface ahead (even / uneven)? | |
Can you use vision to obtain information about height differences in the environment? | |
Can you use vision to orient in: | |
Familiar environments (for example at home)? | |
Unfamiliar environments? | |
Can you find your way in a room by the use of vision? | |
Does your vision function well enough for you to move about freely under changing lighting conditions? | |
Can you orient without discomfort from light? | |
Can you orient in darkness by using vision? |
How does hearing affect your ability to orient in the environment? | |
Do you use hearing to orient in traffic? | |
Are there other auditory techniques that you use for orientation and movement? | |
Do you explore and orient in areas through listening and the use of your own voice (echolocation)? | |
Do you recognise the environment by using hearing? | |
Do you orient towards sound sources? | |
Do you use hearing in relation to directional orientation? | |
Do you use hearing to orient towards sounds at a distance? |
How does the bodily-tactile sense affect your ability to orient in the environment? | |
Can you identify surfaces tactually while moving? | |
How do you experience your balance functioning during movement or orientation? | |
Do you require aids for movement, such as a white cane, guide dog or guide? | |
Do you use tactile markers in familiar environments while moving? | |
How do you create an overview of new environments? | |
Do you actively use the tactile sense to find landmarks in the environment? | |
Do you actively use the tactile sense to navigate in the environment? | |
Do you actively use the tactile sense to recognise different rooms and surroundings? |
How do you experience your own health in terms of how it is affected by the combined sensory loss? Do you have any of the following issues mentioned in the list, and can you relate them to the combined sensory loss? |
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How is your vision affected when you become tired? How are you able to recover so that your vision functions again? | |
How is your hearing affected when you become tired? How are you able to recover so that your hearing functions again? | |
How is your tactile sense affected when you become tired? How are you able to recover so that your tactile sense functions again? | |
How do you find that the senses (vision, hearing and the bodily-tactile sense) function together when you become tired? |
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