JH REHABILITATION

COGNITIVE COMMUNICATION ASSESSMENT FORM

Name:

Age:

D.O.A:

Languages used at home:

Occupation :

Marital status :

Medical diagnosis:

Medications:

Hearing status:

General Behavior observed:

Speech Cognitive Characteristics

Characteristics Never Sometimes Frequently Comments

Difficulty
Understanding Others
Difficulty expressing
wants and needs
Impaired speech
cohesion
Difficulty being
understood by others
Difficulty following
directions/ instructions
Difficulty remembering
information
Difficulty in sustaining
attention in task
Difficulty in reading and
writing
Difficulty in
 communicating
appropriately in a social
situation

BEHAVIOURAL SKILLS:

 Responsiveness to all external stimuli

 May open eyes, suck, and/or yawn
 Responding to others
 Purposeful speech
 Attention and memory:
 Difficulty responding to and/or saying name
 Difficulty expressing basic needs to others using simple words and/or gestures (i.e.,
yes/no, head nod)
 Difficulty saying greetings (i.e., "hi" and "bye") on own
 Difficulty remembering spouse/caregiver's name
 Difficulty counting to 10
 agitated when needs are not met
 Limited eye contact
 Limited social behaviors (i.e., expressions of courtesy and facial expressions)

COMMUNICATION SKILLS:

 Facial expression :
 Prosody
 Difficulty paying attention while speaking (i.e., does not complete sentences or take turns
speaking during conversation)
 May talk too much, monopolizing conversations and not picking up on others’ cues that
they want to take a turn
 Difficulties with understanding humor or sarcasm, or appearing rude, indifferent,
uninterested
  Insensitive to another person’s mood, feelings, needs or ideas.
 Difficulty responding appropriately to message of other individual (i.e., delayed,
preservative, or off-topic responses, including inappropriate words)
 Limited ability to provide biographical information
 Difficulty understanding abstract information; very concrete responses

ORGANISATIONAL SKILLS

 Managing home or maintaining a job or business due to:

 Planning and completing necessary daily activities
 Following directions
 Comprehending or applying abstract written information
 Analyzing personal and/or business problems, identifying and applying solutions
 Assessing own strengths and weaknesses, developing effective plans to improve
weaknesses
 Managing multiple responsibilities simultaneously
 Managing emotions (especially anxiety, frustration, or anger) related to performance
difficulties
 Making, following, and modifying plans as needed
 Understanding and managing personal legal or financial matters (i.e., taxes, buying or
refinancing a home, etc.)
 Effectively communicating with colleagues and/or customers, especially initiating
effective responses, interpreting combined verbal and nonverbal responses during
conversations to determine strategic communication action; modifying responses when
feedback indicates it has not been successful

ACTIVITIES OF DAILY LIVING

Do you require assistance with any of the following ?

Dressing Cooking
 Eating Toileting

Telling time Transportation/driving

House keeping Showering/personal hygiene

House keeping Making phone calls

Keeping track of appointments Money management/ bill

payment
Moving/walking from place to
place

Grocery shopping

COGNITIVE LINGUISTIC ASSESSMENT TEST RESULTS

I Appearance and level of consciousness

II Attention, discrimination and perception

Visual:

 Letter cancellation
 Contingent letter cancellation
 Word cancellation

Auditory

 Sound count
 Letter pair discrimination
 Word pair discrimination
 Month backward naming

III Orientation:

Person –

Place –

Time –

IV Memory:

 Episodic memory
  Working memory
1. Digit forward
2. Digit backward
 Semantic memory
1. Coordinate naming
2. Super ordinate naming
3. Word naming fluency
4. Generative naming
5. Sentence completion
6. Carry out commands

V Problem solving:

 Sentence disambiguation
 Sentence formulation
 Predicting outcomes
 Compare and contrast
 Why questions
 Sequential analysis

VI organization

 Categorization
 Analogies
 Sequencing of events

VII Visuospatial and constructional ability

 Visual acuity deficits, visual agnosia, and visual field cuts

 Right hemisphere language battery
 Supportive Routines
 Humor,
 Questions
 Assertive
 Behaviors
 Narrative
 Variety Of Topic Content,
 Level Of Formality Between Participants,
 Turn-Taking,
 Discourse Comprehension,
 Prosody
 Organization
 Reduced awareness of deficits, or anosognosia

Neglect :

 Personal neglect
 Peripersonal neglect
 Extra personal neglect
 Neglect dysgraphia
 Neglect dyslexia
The level of assistance required of executive function is measured through a hierarchy
of cueing: 0. No cues. 1. Indirect cues 2. Gestures or pointing. 3. Direct cues. 4.
Physical Assistance 5. Do for the participant.