Assesment form
Please fill the information about the patient
1.1 Name *
1.2 Surname *
1.3 Address *
1.4 Age *
1.5 Clinical and Functional Evaluation *
(Pathology, onset, evolution, etc.)
1.6 Detailed Diagnosis
(If possible, please send us through email clinical exam results like TAC, RMN)
1.7 Cognitive condition *
1.8 Involuntary head/neck movements *
1.9 Ongoing antidepressant/painkiller therapy *
Required
1.10 Motivation of the patient towards Augmentative Alternative Communicator *
1.11 Use of other communication aids *
Next
Never submit passwords through Google Forms.
This form was created inside of Pasquale Fedele. Report Abuse