Form Ag-095 - Arizona Standardized Client Assessment Plan (Ascap) Page 5
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15AG-095 (11-14) – Page 5
CLIENT’S NAME
DAARS ID NO.
Place (immediate environment, residence, city, state).
Disoriented occasionally (3 times or less per month).
Disoriented some of the time (more than 3 times per month but less than half the time).
Disoriented at least half the time.
No problems with orientation.
Time (day, month, year, time of day).
Disoriented occasionally (3 times or less per month).
Disoriented some of the time (more than 3 times per month but less than half the time).
Disoriented at least half the time.
No problems with orientation.
Recent memory recall.
Minimally impaired function.
Moderately impaired function.
Severely impaired function and safety.
No problem with memory recall.
COMMENTS
B. Communication/Sensory (Check appropriate answer. Consider last 30 days.)
Hearing – The ability to perceive sounds (with hearing appliance, if used).
Minimal difficulty (e.g., understands conversation when face to face).
Hears in special situations only (e.g., speaker has to adjust tonal quality and speak distinctly), will only understand loud
conversation.
Absence of useful hearing (e.g., will hear only very loud voice; totally deaf).
Hears adequately (e.g., conversation, TV, phone).
Expressive Communication – The ability to express information and making self understood using any means (making self
understood by others).
Difficulty finding words, finishing thoughts, or enunciating.
Ability is limited to making concrete requests.
Rarely/never understood.
Understood.
Vision – The ability to perceive visual stimuli (with corrective devices, if used).
Difficulty with focus at close (reading) range. Sees large print and obstacles, but not details or has monocular vision.
Unable to see large print, field of vision is severely limited (e.g., tunnel vision or central vision loss).
No vision or appears to see only light, colors or shapes.
Sees adequately (e.g., newsprint, TV, medication labels).
Smell – The ability to perceive odors/scents, especially odors indicating a danger (e.g., smoke).
Impairs safety.
Does not impair safety.
Touch – The ability to discriminate against temperature (e.g., hot, cold), dull and sharp, and pain (e.g., resulting from an open wound).
Impairs safety.
Does not impair safety.
COMMENTS
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