SPEECH THERAPY EVALUATION

1SPEECH THERAPYEVALUATION PG 1 > 2SPEECH THERAPYEVALUATION PG 2 > 3Review Your Entry
DATE OF SERVICE DATE OF SERVICE / MM / DD YYYY
PATIENT NAME PATIENT NAME First Last
PATIENT DOB PATIENT DOB / MM / DD YYYY
PATIENT'S DATE OF INJURY
INSURER TYPE
INSURER
CLAIM NUMBER
ICD 10 CODE
ICD 10 CODE
ICD 10 CODE
LOCATION OF TREATMENT

LOCATION OF TREATMENT HOME VISIT (12) OFFICE VISIT (11) TELEHEALTH - IN HOME (10) TELEHEALTH - NOT IN HOME (02) ASSIST LIVING FACILITY (13) GROUP HOME (14) TEMPORARY LODGING (16) PLACE OF EMPLOYMENT (18) SKILLED NURSING FACILITY (31) NON SKILLED NURSING FACILITY (32) OTHER (99) OTHER (99)
PERTINENT BACKGROUND INFORMATION
PRIMARY/TREATMENT DIAGNOSIS / PROBLEM:
MEDICAL PRECAUTIONS:
OTHER PERTINENT MEDICAL / SOCIAL HISTORY AND/OR PREVIOUS THERAPY:
PRE-INJURY LEVEL OF FUNCTION IN ADLS

PRE-INJURY LEVEL OF FUNCTION IN ADLS INDEPENDENT SOME ASSISTANCE TOTAL ASSISTANCE
REPORTED BY

REPORTED BY PATIENT FAMILY CAREGIVER OTHER OTHER
LIVING ARRANGEMENTS

LIVING ARRANGEMENTS LIVES ALONE CAREGIVER AVAILABLE LIMITED SUPPORT NO CAREGIVER AVAILABLE
COMMENTS
HISTORY OF FALLS

HISTORY OF FALLS YES NO
If yes, date of last fall: If yes, date of last fall: / MM / DD YYYY
VITALS
WERE VITALS TAKEN?
TEMPERATURE
BLOOD PRESSURE
PULSE
RESPIRATIONS
SpO2
USING O2 AT _____ LPM
via
PAIN ASSESSMENT
PAIN RATING 0 (LOWEST) -10 (HIGHEST)
LOCATION(S) OF PAIN
IS PAIN IMPAIRING FUNCTION

IS PAIN IMPAIRING FUNCTION YES NO
TYPE OF PAIN

TYPE OF PAIN CHRONIC PAIN ACUTE PAIN
SWALLOWING
SAFE SWALLOWING EVALUATION?

SAFE SWALLOWING EVALUATION? YES NO
If yes, specify Date, Facility and Physician (if known)
VIDEO FLUOROSCOPY?

VIDEO FLUOROSCOPY? YES NO
If yes, specify Date, Facility and Physician (if known)
DOES PATIENT HAVE SPECIFIC DIET?
CURRENT DIET LEVEL
LIQUIDS:

LIQUIDS: THIN THICKENED
If thickened, specify
SPEECH / LANGUAGE EVALUATION

4 – WFL 3 – Mild impairment 2 – Moderate impairment 1 – Severe impairment 0 – Unable /did not test
COGNITION
COGNITION ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Orientation	Orientation4	Orientation3	Orientation2	Orientation1	Orientation0
Attention span	Attention span4	Attention span3	Attention span2	Attention span1	Attention span0
Short-term memory	Short-term memory4	Short-term memory3	Short-term memory2	Short-term memory1	Short-term memory0
Long-term memory	Long-term memory4	Long-term memory3	Long-term memory2	Long-term memory1	Long-term memory0
Judgment	Judgment4	Judgment3	Judgment2	Judgment1	Judgment0
Problem solving	Problem solving4	Problem solving3	Problem solving2	Problem solving1	Problem solving0
Organization	Organization4	Organization3	Organization2	Organization1	Organization0

COMMENTS
SPEECH / VOICE
SPEECH/VOICE ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Oral/facial exam	Oral/facial exam4	Oral/facial exam3	Oral/facial exam2	Oral/facial exam1	Oral/facial exam0
Articulation	Articulation4	Articulation3	Articulation2	Articulation1	Articulation0
Prosody	Prosody4	Prosody3	Prosody2	Prosody1	Prosody0
Voice / Respiration	Voice / Respiration4	Voice / Respiration3	Voice / Respiration2	Voice / Respiration1	Voice / Respiration0
Speech Intelligibility	Speech Intelligibility4	Speech Intelligibility3	Speech Intelligibility2	Speech Intelligibility1	Speech Intelligibility0

COMMENTS
SWALLOWING
SWALLOWING ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Chewing ability	Chewing ability4	Chewing ability3	Chewing ability2	Chewing ability1	Chewing ability0
Oral stage management	Oral stage management4	Oral stage management3	Oral stage management2	Oral stage management1	Oral stage management0
Pharyngeal stage management	Pharyngeal stage management4	Pharyngeal stage management3	Pharyngeal stage management2	Pharyngeal stage management1	Pharyngeal stage management0
Reflex time	Reflex time4	Reflex time3	Reflex time2	Reflex time1	Reflex time0

COMMENTS
VERBAL EXPRESSION
VERBAL EXPRESSION ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Augmentative methods	Augmentative methods4	Augmentative methods3	Augmentative methods2	Augmentative methods1	Augmentative methods0
Naming	Naming4	Naming3	Naming2	Naming1	Naming0
Appropriate Yes = 4 No = 1	Appropriate Yes = 4 No = 14	Appropriate Yes = 4 No = 13	Appropriate Yes = 4 No = 12	Appropriate Yes = 4 No = 11	Appropriate Yes = 4 No = 10
Complex sentences	Complex sentences4	Complex sentences3	Complex sentences2	Complex sentences1	Complex sentences0
Conversation	Conversation4	Conversation3	Conversation2	Conversation1	Conversation0

COMMENTS
AUDITORY COMPREHENSION
AUDITORY ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Word discrimination	Word discrimination4	Word discrimination3	Word discrimination2	Word discrimination1	Word discrimination0
1 step directions	1 step directions4	1 step directions3	1 step directions2	1 step directions1	1 step directions0
2 step directions	2 step directions4	2 step directions3	2 step directions2	2 step directions1	2 step directions0
Complex directions	Complex directions4	Complex directions3	Complex directions2	Complex directions1	Complex directions0
Conversation	Conversation4	Conversation3	Conversation2	Conversation1	Conversation0
Speech reading	Speech reading4	Speech reading3	Speech reading2	Speech reading1	Speech reading0

COMMENTS
READING
READING ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Letters/Numbers	Letters/Numbers4	Letters/Numbers3	Letters/Numbers2	Letters/Numbers1	Letters/Numbers0
Words	Words4	Words3	Words2	Words1	Words0
Simple sentences	Simple sentences4	Simple sentences3	Simple sentences2	Simple sentences1	Simple sentences0
Complex sentences	Complex sentences4	Complex sentences3	Complex sentences2	Complex sentences1	Complex sentences0
Paragraph	Paragraph4	Paragraph3	Paragraph2	Paragraph1	Paragraph0

COMMENTS
WRITING
WRITING ASSESSMENT COMPLETED

FUNCTION EVALUATED
FUNCTION EVALUATED	4	3	2	1	0
Letters/Numbers	Letters/Numbers4	Letters/Numbers3	Letters/Numbers2	Letters/Numbers1	Letters/Numbers0
Words	Words4	Words3	Words2	Words1	Words0
Sentences	Sentences4	Sentences3	Sentences2	Sentences1	Sentences0
Spelling	Spelling4	Spelling3	Spelling2	Spelling1	Spelling0
Formulation	Formulation4	Formulation3	Formulation2	Formulation1	Formulation0
Simple addition/subtraction	Simple addition/subtraction4	Simple addition/subtraction3	Simple addition/subtraction2	Simple addition/subtraction1	Simple addition/subtraction0

COMMENTS
Save my progress and resume later
Enter Your Email Address *

A special link to resume the form will be sent to your email address.

SPEECH THERAPY EVALUATION

SPEECH THERAPY EVALUATION

PERTINENT BACKGROUND INFORMATION

VITALS

PAIN ASSESSMENT

SWALLOWING

SPEECH / LANGUAGE EVALUATION

COGNITION

SPEECH / VOICE

SWALLOWING

VERBAL EXPRESSION

AUDITORY COMPREHENSION

READING

WRITING