Consultation Questionnaire
Please answer the questions below to represent the client's daily experiences.
Name
First Name
Last Name
Are there dark areas in the room/house?
Yes
No
Is there more than one light source in the room?
Yes
No
Is the floor carpeted?
Yes
No
Is there excessive noise from the t.v. or audio?
Yes
No
Is there excessive noise outside?
Yes
No
Are drawers and cabinets labeled?
Yes
No
Are there throw rugs on the floor?
Yes
No
Are there quiet places for conversation?
Yes
No
Is the person able to walk?
Yes
No
Does the person use a wheelchair?
Yes
No
Does the person use a walker?
Yes
No
Is the person bed bound?
Yes
No
Does the person have visual deficits? (other than corrective glasses)
Yes
No
Has the person's eating habits changed?
Yes
No
Can the person learn something new (new game, remote control, etc)?
Yes
No
Can the person say at least one word? (if no, please answer 17 and 18)
Yes
No
Can the person make sounds or vocalizations?
Yes
No
Does the person turn their head in response to noises?
Yes
No
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Next
Please respond to the questions below related to your daily experience with the person. (circle the most accurate response)
Communication/Recall
Communicates their needs:
Never
Sometimes
Frequently
Always
Communicates their desires:
Never
Sometimes
Frequently
Always
Follows simple, 1-step directions:
Never
Sometimes
Frequently
Always
Follows multi-step directions:
Never
Sometimes
Frequently
Always
Is able to look for items not in plain sight:
Never
Sometimes
Frequently
Always
Is easily confused:
Never
Sometimes
Frequently
Always
Able to recall long-term information: (past information)
Never
Sometimes
Frequently
Always
Able to recall short-term information: (daily information)
Never
Sometimes
Frequently
Always
Able to follow a schedule using calendars, etc. to get to appointments at appropriate times:
Never
Sometimes
Frequently
Always
Able to sort items such as silverware and clothing:
Never
Sometimes
Frequently
Always
Able to read words:
Never
Sometimes
Frequently
Always
Able to identify pictures or objects:
Never
Sometimes
Frequently
Always
Recognizes familiar friends and family:
Never
Sometimes
Frequently
Always
Participates in social interactions with family and friends:
Never
Sometimes
Frequently
Always
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Activities of Daily Living
Participates in grooming: (brusing hair/teeth, shaving, applying make-up)
Never
Sometimes
Frequently
Always
Participates in dressing their upper body:
Never
Sometimes
Frequently
Always
Participates in dressing their lower body:
Never
Sometimes
Frequently
Always
Able to put on/take off their own shoes:
Never
Sometimes
Frequently
Always
Able to feed themselves: (NOT preparing meals)
Never
Sometimes
Frequently
Always
Able to complete simple household tasks independently:
Never
Sometimes
Frequently
Always
Able to hold and use familiar objects, such as utensils:
Never
Sometimes
Frequently
Always
Able to hold an item and use it with maximum direction:
Never
Sometimes
Frequently
Always
Able to make large body movements such as raising their arm to get dressed:
Never
Sometimes
Frequently
Always
Able to sit independently and take a few steps when transferring:
Never
Sometimes
Frequently
Always
Please use this space if you want to include any additional information:
Submit
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