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Cognitive Communication Form

The document is a cognitive communication assessment form that collects information about a patient such as their name, age, languages spoken, medical diagnosis, and medications. It assesses the patient's speech, cognitive, behavioral, communication, organizational, and daily living skills through a series of questions about their abilities rated on scales of never, sometimes, or frequently. It also documents the results of cognitive and linguistic tests administered to further evaluate the patient's attention, memory, problem solving, and other cognitive functions.

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Sureaka Ponnusamy
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111 views7 pages

Cognitive Communication Form

The document is a cognitive communication assessment form that collects information about a patient such as their name, age, languages spoken, medical diagnosis, and medications. It assesses the patient's speech, cognitive, behavioral, communication, organizational, and daily living skills through a series of questions about their abilities rated on scales of never, sometimes, or frequently. It also documents the results of cognitive and linguistic tests administered to further evaluate the patient's attention, memory, problem solving, and other cognitive functions.

Uploaded by

Sureaka Ponnusamy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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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.

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