Comments (i.e. type of lift, description of transfer): □ □ Communication: Understands Speech Yes No Comments: □ □ □ □ □ Speaks: Yes No Conversational Limited speech Vocalizations Comments: □ □ □ □ Non-Verbal Eye Blinks Gestures Manual Signing □ □ Communication board Communication Device □ Other/Comments □ □ Able to read: Yes No Comments: □ □ English is secondary language: Yes No Comments: □ □ □ □ □ c. Partially deaf Deaf Visually impaired Blind Color blind Sensory Impairments: □ Tactile defensive / please explain: □ □ □ □ □ Sensory aids used: Hearing aid Right ear Left ear Glasses Contacts □ Other (describe): □ □ d. Behaviors: Is this person seen by Waisman TIES staff? Yes No If yes, whom? □ □ □ Non-compliance Self-injurious behaviors Physical aggression towards others □ □ □ Destruction of property Physically resistive to cares Other, please explain Please list any other helpful information such as stress factors, approaches or strategies which WIN nurses could use when interacting with the individual: Medical History and Current Condition □ □ Seizures: Yes No If yes, please forward a copy of Seizure Protocol to this office. □ □ □ □ History of seizures: Yes No Currently Controlled: Yes No □ □ □ □ Does individual have a Vagus Nerve Stimulator? Yes No Is Rectal Diastat prescribed? Yes No Who is the doctor that oversees this seizure disorder? Physician Name: individual’s Name of Clinic:
Comments (i.e. type of lift, description of transfer): Communication: Understands Speech □ Yes □ No Comments: Speaks: □ Yes □ No □ Conversational □ Limited speech □ Vocalizations Comments: □ Non-Verbal □ Eye Blinks □ Gestures □ Manual Signing □ Communication board □ Communication Device □ Other/Comments Able to read: □ Yes □ No Comments: English is secondary language: □ Yes □ No Comments: c. Sensory Impairments: □ Partially deaf □ Deaf □ Visually impaired □ Blind □ Color blind □ Tactile defensive / please explain: Sensory aids used: □ Hearing aid □ Right ear □ Left ear □ Glasses □ Contacts □ Other (describe): d. Behaviors: Is this person seen by Waisman TIES staff? □ Yes □ No If yes, whom? □ Non-compliance □ Self-injurious behaviors □ Physical aggression towards others □ Destruction of property □ Physically resistive to cares □ Other, please explain Please list any other helpful information such as stress factors, approaches or strategies which WIN nurses could use when interacting with the individual: Medical History and Current Condition Seizures: □ Yes □ No If yes, please forward a copy of Seizure Protocol to this office. History of seizures: □ Yes □ No Currently Controlled: □ Yes □ No Does individual have a Vagus Nerve Stimulator? □ Yes □ No Is Rectal Diastat prescribed? □ Yes □ No Who is the doctor that oversees this individual’s seizure disorder? Physician Name: Name of Clinic: