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What percentage of your/the client's speech is understandable?

e.g. 0-25%, 25-50%, 50-75%, 75-90%, 90-100%

Do you/the client have difficulty understanding spoken instructions or conversation?

Give an example, if you can think of one.

Do you/the client have difficulty understanding written instructions?

Give an example if you can think of one.

Do you/the client have difficulty swallowing?

If so, what textures or liquid consistencies?

Have you had any previous speech therapy?

If so, specify when and where.

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.