Expressive or receptive aphasia assessment form:
History
Name ------------------------------
Age ------------------------------
Sex ------------------------------
Marital Status -----------------------
Family -------------------------------
First Language -------------------------
Date of Onset -----------------------
Time since Onset ------------------------
Medical Complications ------------------------------------------------Physical Appearance -------------------------------------------------Post-medical History ------------------------------------------------Cause of Speech/Language ------------------------------------------Handedness ---------------------------------General history
Mobility ---------------------
Paralysis ---------------------
Posture --------------------
Facial symmetry ---------------
Vision ---------------------
Hearing ---------------------
Spontaneous speech (content)
How are you today?
-----------------------------------------------------------------------------------What is your full name?
-----------------------------------------------------------------------------------Why are you here? (In hospital)
-----------------------------------------------------------------------------------What is this called?
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Auditory verbal comprehension: Yes /No Questions
1. Is your name ali?
2. Is the door closed?
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3. Are the lights on in this room? ------------4. Are you sitting on the chair? ------------5. Are you having 2 hands? ------------Repetition
1. Pot
2. Carrot
3. Forty five
4. The silver moon hung in the dark sky
5. Bed