Form Ddd-1151a - Augmentative Alternative Communication (Aac) Referral Packet Page 4
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9DDD-1151A FORFF (1-18)
Page 4 of 9
Complete the information below. You may consult with family/therapists. Please add as much descriptive information as
possible to assist the evaluators in providing a thorough evaluation.
Based on your interactions with the Member check the applicable boxes below (Check all that apply)
Ability to hold head up:
Good
Fair
Poor
Describe:
Ability to sit without support:
Good
Fair
Poor
Describe:
Muscle tone in arms/hands:
Floppy
Average
Stiff
Varies
Describe:
Muscle tone in legs/feet:
Floppy
Average
Stiff
Varies
Describe:
Walking ability:
Independently
With assistance
Does not walk
Describe:
Balance:
Steady
Fair
Poor
Falls frequently
Describe:
Mobility aides:
AFO’s
Cane
Crutches
Walker
Scooter
Wheelchair
Other:
Describe:
If member uses a wheelchair(s):
Manual - Type:
Self-propels:
Yes
No
Stroller:
Yes
No
Power - Type:
Drives independently:
Yes
No
Joystick control location:
Describe:
Describe any problems with the current wheelchair system:
Does the member have upcoming changes in his/her seating system?
Yes
No
Explain:
Does the member use a tray with the wheelchair?
Yes
No
Describe:
Are there any safety or other concerns related to mobility?
Yes
No
Describe:
Hand preference:
Right
Left
Both
Unknown
Describe:
Ability to use hands:
Not able to use hands
Right only
Left only
With no difficulty
With limited movement/coordination
Describe:
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