(see House, 2002b for further details and example)
V
H
S
M
O
M
J
C
I
VF
VC
A
M
T
(hand used for writing)
g
p
m
s
a
d
Figure 11-3: Categories for Observation During the Session
VISION: wearing glasses, report of contact; apparent visual acuity
HEARING: gross registration of conversational speech
SPEECH: articulation; rating on MAE Speech Articulation scale
MOTOR COORDINATION: gross motor, fine motor
ORIENTATION: within normal limits, poor, impaired; error score on Benton Orientation Test
MEMORY: normal, fair, poor, impaired
JUDGEMENT: normal, fair, poor, impaired
CONCENTRATION: normal, distractible, attention deficit
INTELLECTUAL FUNCTIONING: grossly normal, low average-borderline, impaired
VERBAL FLUENCY: normal, word finding problems, aphasic
VERBAL COMPREHENSION: normal, receptive language problems
AFFECT: appropriate/inappropriate; labile, blunted, flat
MOOD: normal, depressed, anxious, angry
THOUGHT PROCESSES: normal, concrete, confused, psychotic
(hand used for writing): right, left, no predominant
grip: used for writing: standard, typical variations, fist, variable;
good, adequate, poor control
placement: of hand on pencil shaft: normal, low high
medication: current prescription and over-the-counter medications
smoke: cigarettes smoked per day and other tobacco use
alcohol: frequency and amount of alcohol use reported
drugs: report of any illicit drug use