Fundional Communication Profile - Revised™

, ' Larry I. Kleiman

o INITIAL EVALUATION
NAME DATE

ORE-EVALUATION

o TRI-ANNUAL EVALUATION BIRTHDATE AGE LOCATION

DIAGNOSIS

Method{s) of
Administration

o Direct Assessment

o Informal Observation SPEECH & LANGUAGE EVALUATION

o Review of Records
NORMAL MILD MODERATE SEVERE PROFOUND
o Informant Interview
Sensory 0 0 0 0 0
(Relationship)

Motor 0 0 0 0 0

Behavior LJ 0 0- 0 0

Attentiveness 0 [j 0 0 [j

Receptive Language LJ 0 0 0 0

Expressive Language 0 0 0 0 0

Pragmatic/Social 0 0 0 0 0

Speech 0 0 0 0 0

Voice 0 0 0 0 0

Oral 0 0 0 0 0
--~~----_._--,._.

Fluency 0 0 0 0 0 n/a

--.----- - - - --_.- ---- .--- - ._---- -- ---- ---_ -_ ..

.. - - - - - - - - . - - - - - - - --_.--._- ------_._-------------_._-_._---­
RELEVANT HISTORY

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SENSORY 1 MOTOR c ": "," , ;

o Hearing

o Auditory Localization

o Vision o functional 0 possible loss 0 medical condition 0 blindness

o impaired (severity or type): _~ ,, ~ ~__ ~_

[l lenses prescribed ~__wom _ _not worn 0 lenses not prescribed

o Eye Contact 0 adequate 0 mild deficits 0 fair 0 poor

0 best w/objects 0 best w/persons 0 avoids 0 none
0 n/a due to blindness
-----
o Visual Tracking 0 adequate 0 fair 0 inconsistent 0 poor
0 best w/objects 0 best w/persons 0 none 0 n/a
,----,-_._----------"
o Visually Inspects Objects 0 adequate o inconsistent o poor o none
------,-_.~--------------

o Grasp C adequate o fair o momentary 0 passive

o randomly tosses o unable o motor impaired, but possible

o Self-Help Skills o independent o needs assist o dependent o mixed

,---------------­
o Head & Trunk Positioning communication/swallowing implications: __ . _ ,,_

o Gross Motor 0 ambulatory 0 poor coordination o poor balance 0 non-ambulatory

o Accepts Being
Physically Guided 0 yes 0 no 0 partially [J resistive
0 tactile defensive [l motor restrictions 0 varies with person or situation
-------
o Motor Imitation 0 unprompted 0 w/physical prompt 0 completely assisted 0 refused
0 n/a - lacks vision 0 movement restricted 0 gross but not fine motor
----~-_._-_. --------­
o Inappropriate Behavior 0 stereotyped repetitive motor mannerisms 0 stimulus fascination (lights, smells, etc.)
0 avoids physical contact or ignores 0 stimulus oversensitivily
0 prefers objects to persons U poor sensory integration
[l physical aggression 0 excessive/ritual speech
0 verbal aggression 0 restricted interests/eccentric
0 mouthing inedibie objects/body parts 0 frequent clothes changing
0 social isolation/withdrawal 0 poor social boundaries
0 adheres to nonfunctional routines [J poor safety awareness

[J preoccu pation w/object part 0 compulsive or rigid C food stealing

0 tantrums o echolalia 0 rejects change 0 hoarding
0 self-abuse 0 self-talk [J lacks real fear 0 hype ractivity
0 property destruction 0 swears/cu rses 0 irrational fears D easily agitated
0 PICA 0 threatens D noncompliant 0 none reported/observed
0 other: _

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o Attention Span [] adequate [] mild deficits [] fair :::J poor

[] fatigues :::J varies w/mood 0 object preoccupation [] none

o Distractible 0 almost never 0 occasionally 0 moderately [] frequently

:::J constantly 0 not observed 0 depends on task or time

o Alertness 0 adequate [l moderate [] low [] lethargic

:::J non-responsive [] selective

o Response Rate [] appropriate [] impulsive [] mild delays

[] moderate delays [] severe delays [] no response

:::J mixed ( _ best receptively _ best expressively)

o Awareness of Others [] adequate 0 fair 0 poor 0 non-existent

[] seeks others 0 disregards others 0 maintains interaction

o Awareness of
Environmental Events [] usually 0 moderately 0 occasionally 0 rarely
[] never 0 sensory impaired 0 physical status restricts

o Cooperation o adequate Ow/some prompts Ow/numerous prompts :::J resists

RECEPTIVE LANGUAGE

o Native language
o languages Understood
o Oral Comprehension 0 words 0 phrases 0 sentences :::J none
0 simple 0 complex 0 direct & indirect 0 only direct
conversations conversations requests requests
:::J literal but not 0 n/a due to 0 uses sign
figurative hearing loss language
------,_._-_.

o Understands
Basic Concepts U functional 0 limitations 0 poor o none
Check Concepts Understood:
o colors 0 body parts 0 size 0 shape
o money 0 object function 0 prepositions 0 categories
o same/different 0 more/less 0 opposites/synonyms 0 how many
Demotions 0 physical property 0 time 0 quantity
------
o Responds to Name o on request Ow/sign 0 w/gesture o sensory loss
i'1 no response Ow/physical prompt 0 may tune out others

o Responds to
Attention Commands o on request [] w/sign [] w/gesture o refuses
(No, Stop, Look)
n unable Ow/physical prompt

o looks at Pictures [J w/interest o mildly attentive o lacks interest o no

r~ only w/photos o items, not scenes On/a

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Receptive Language, continued

o Accepts Objects
Presented 0 by request 0 w/gesture 0 w/physical prompt 0 w/total assistance
0 motorically unable 0 rejects 0 no response 0 spontaneously

o Gives Objects to Speaker 0 by request 0 w/gesture 0 w/physical prompt 0 refuses

0 w/total assistance 0 no response 0 motorically unable 0 only if exchanging

o Routine Commands V '= w/verbal comments T '= wltotal assistance P '= w/physical prompt G '= w/gesture
S '= w/signing instruction M '= w/motor impairments R '= refused U '= unable
Types of Commands:
o head up 0 swallow 0 push/pull 0 touch it
o shake item/limb 0 turn on/off 0 hands down 0 smile
0 hold 0 sit 0 stand 0 come here
0 go 0 open/close mouth 0 handshake 0 clap

o Environmental
Commands 0 followed on request [J w/repeated command
0 w/gestural prompt 0 w/physical prompt
0 multi-step commands 0 w/written instruction
0 total assistance required 0 may understand but is motorically restricted
0 w/sign 0 needs situational cues
0 w/picture cues 0 follows routine
0 no response 0 refuses or uncooperative

o Nonverbal
Comprehension 0 gestures 0 intonation changes
0 sarcasm 0 facial expressions
0 other's feelings & thoughts 0 social cues
0 body language 0 voice affect of speaker
0 context 0 n/a due to sensory loss

o Object Identification 0 verbal request 0 w/gesture 0 w/physical prompt 0 w/sign

0 by function 0 w/tactile exploration 0 w/limited items 0 none

o Two-Dimensional
Recognition 0 photos. 0 line drawings 0 color drawings o symbols
0 visual deficits 0 safety signs 0 community logos o requires large pictures
0 unable 0 relies on context cues 0 understands picture represents message or concept
Mode of Presentation:
o on verbal request o signed o written o pantomime
o pointing prompt o PECS o match object w/picture o match picture w/picture

EXPRESSIVE LANGUAGE

o Languages Expressed
o Verbal Status o nonverbal
communicator
o verbal
communicator
o non-oral
communicator
o total communication
communicator
o limited verbal o limited non-oral o lacks communication
communicator communicator

o Expressive Level o one unit o single words o phrases o sentences

(Check highest level.) o conversation o n/a

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Expressive Language, continued

o Basic Communication
Expression
(Check all that apply.)

imitates speech
sign language
fingerspells
alphabet set
writes
I-------,------+------f-------+------j
types
picture system/
PECS
word system
eye gaze
communication
device
facilitation
vocalizes
points/gestures

facial expres~~o_n_+- _l-_----_+-'-'-'-';;......l--'-'-'-'+-----_l

takes object
body movements
shows 10 tag
or card
head nod answer
not expressed
.-
__=±==_
---=­~=-r-==----
J

o Uses Common Gestures 0 spontaneous 0 w/gestural prompt U w/pnysical prompt o none

o Grammar Skills 0 excellent 0 adequate 0 fair o poor

0 none means:
~ -
o Vocabulary 0 extensive o basic/functional o limited o n/a
Check All Types Used:
0 objects 0 person 0 places 0 categories
0 present-tense action 0 past-tense action 0 future-tense action 0 possession
0 social forms [l slang 0 quantity 0 plurals
0 pronouns 0 location/direction 0 yes/no 0 time concepts
C action quality 0 object quality 0 idiomatic expression 0 physical &
(adverbs) (adjectives) (colloquial) emotional states
0 similes, metaphors, puns C swearing
-----­ _. _.,-~,..~-~

o Average Phrase Length words Imitation Span words

Indicate Means:
0 spoken 0 signed 0 picture/symbol [l printed message

U communication device 0 n/a 0 other: ­

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PRAGMATIC/SOCIAL LANGUAGE' , .,' .

o Communicative Intent 0 request item/action 0 call/summon 0 complimenVpraise 0 deny/negate

0 ask for 'more' 0 seek/direct care [J describe item/act 0 affirm
0 gain attention 0 seek affection 0 express gratitude 0 instruct
0 protest/resist 0 seek approval 0 make plans 0 deceive
0 greeVtake leave 0 interrupt others 0 make friends 0 remind
0 command 0 socialize 0 assert self 0 criticize
0 request assist 0 offer assist/warn 0 offer empathy 0 persuade
0 inform about self 0 comment 0 self advocate 0 insult
0 inform about others 0 agree 0 repair conversation 0 apologize
0 provide information 0 argue or disagree 0 request clarification 0 controi
0 show interest in others/activity 0 clarify meaning/explain
0 to play with others 0 suggesVadvise 0 share interests/objects w/others
0 inquire 0 none demonstrated 0 other:

o Initiates Communication 0 appropriately 0 moderately 0 if asked/prompted 0 rarely

0 occasionally 0 excessively 0 only egocentric 0 none

o Answers Who, What, 0 consistently 0 inconsistently 0 minimally 0 not able

& Where Questions

o Answers When, Why, 0 consistently 0 inconsistently 0 minimally 0 not able

& How Questions

o Answers Yes/No 0 consistently 0 inconsistently 0 minimally 0 not able

Questions 0 randomly (indiscriminate) 0 only concerning needs or desires
------_._._-----------,---­
o Asks Questions 0 simple forms 0 complex forms 0 uses changes in vocal inflection
0 via gestures 0 none elicited/emitted 0 reported but not observed
0 interviews listener 0 only concerning self 0 unable
-----_.~~~ .._-­

o Conversational Skills 0 appropriate 0 need improvement 0 limited 0 none

0 nonverbal 0 vary w/listener 0 vary w/mood
-----~._-_._------------~----~

o Communication Partners 0 family 0 peers or coworkers 0 staff/caregiver 0 instructor

0 community member 0 job coach/supervisor 0 poor interest in relationships
0 none 0 other:
..
_---~ . _.. _---,_..__ ._,-~,~-----,-----_ .._-_.__.. '~.--_._.,,--_ ..__ .--->._----------,-~

o Conversational Topics 0 of mutual interest 0 self-centered 0 appropriately about self

[J irrelevanVtangential [] perseverative 0 about rituals
0 none initiated 0 n/a
-_._._--_._-,--~"-_._---_.~ .. _~_._.~~""-~--_ .. _~,_" _ _ _ _ _ _ _ _ ,~· _ _ _ , _ , _ ~ _ _ . · r _ _ _ • _ _ _ _ _ _ ~a

o Turn-Taking o appropriate o needs cues

occasionally
0 needs cues
moderately
0 needs cues
frequently
o fails to attend o dominates the 0 uninterested in 0 unable
to listeners conversation exchanging
o n/a

Topic Initiation o independent Ow/occasional 0 only w/ assistance 0 none

assistance or prompting
o n/a ­ no means o excessive for odd (circumscribed)/unusual topics

Copyright 2003 LingurSystems. Inc. 7

Pragmatic! scctet Language, continued

o Topic Maintenance o adequate o prompted 0 minimal o unsuccessful

o rapidly shifts o lacks interest/motivation On/a

o Topic Elaboration number of different statements:

o independently o indirect verbal cues 0 direct verbal prompts
Ow/graphic cues o only for fixations 0 not stimulable 0 nonverbal

o Cause-Effect Reasoning 0 appropriate response or explanation o routine/rote response or explanation

o fair response or explanation o only if prompted or directed
o not expressed o n/a

o Shares Personal Data

o Appropriateness o consistent U inconsistent o occasional o random

of Communication Descriptive Conditions (Check all that apply.)
o considers listener's perspective __ yes no
o uses social rules __ yes no o knows where to say it
o knows what to say o impaired topics
o knows when to say it o nonverbal

o Discusses News Events o specific 0 general o vague o unaware/no interest

o rote repetition w/o meaning or relevance o unable to express

o Reading/Literacy o letters o name o 'numbers o key words

C survival words 0 phrases o paragraphs o store signs
o product labels(logos) 0 none

o Writing/Spelling o letters o numbers o key words [' name

o phrases o conversation o facilitated o none

o Memory Short Term:

o functional o limitations 0 no recall o not testable
long Terrrt:
o functional o limitations/selective 0 no recall o not testable
o savant-like skills or calculations

SPEECH

o Intelligibility o easily understood by others o understood w/minor difficulty

o understood w/moderate difficulty o understood w/major difficulty
o not understandable o nonverbal or n/a
Proficiency Level:
C words o phrases o conversation o context must be known

o Understood By o familiar others o trained listeners 0 average listeners o all listeners

o no one o dialect may interfere with intelligibility

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o Adjusts Speech to 0 successful 0 no change required 0 sometimes 0 rarely

Improve Understanding 0 unsuccessful 0 self-corrects 0 requires constant cues
0 nonverbal

o Sounds Produced 0 beginning (vowels, p, b, m, h, w, n, ng) 0 intermediate sounds (y, k, g, f, d)

0 advanced intermediate (t, ch, r, sh, s, v, I) 0 advanced (th, j, zh, z, wh)
0 consonant blends 0 nonspeech sounds
o age appropriate o delayed 0 generalized distortions

o Error Phonemes

o Omitted Phonemes

o Dentition 0 unremarkable 0 overbite 0 underbite 0 open bite

0 overcrowding 0 repaired cleft 0 minimal dentition 0 wears braces
0 removable dentures 0 absent 0 poor condition 0 uncoope rative
0 some teeth are missing

o Articulators

o Oral-Motor Imitation

VOICE

o Loudness 0 adequate 0 excessive 0 variable [J inadequate

0 low intensity 0 monoloudness 0 nonverbal/non-oral 0 fades
0 inappropriate to setting 0 reduced breath support

o Vocal Quality 0 normal 0 nasal 0 hoarse 0 harsh

0 strained 0 whining 0 strident 0 breathy
0 whispered 0 explosive 0 vocal fry 0 wet dysarth ria
0 diplophonia 0 vocal tremors 0 spastic dysphonia 0 singsong
0 nonverbal/non-oral 0 cul-de-sac resonance
•.
-_._~-~-~_._-~-__"--_.~."--_._._--_._~-_. ~---~~-_ ..
_._~---~,-~---

o Pitch 0 appropriate 0 higher than normal 0 lower range 0 variable

0 monotone 0 immature for age 0 falsetto 0 nonverbal
0 pitch breaks [l mimics other's pitch 0 inappropriate rising inflection
0 changes for ritual speech or echolalia 0 inappropriate for gender

.----------_.- ---- -~-

--_._-- -"------­

Copyright 2003 LinguiSystems, Inc. 9

o Mouth Breather D always D most of the time D some of the time D not a problem
D tracheostomy D due to nasal congestion

o Drooling D absent D on occasion D frequently D not observed

D nearly always D self-monitors D unmonitored
D medication prescribed D requires protective measures

o Tongue Thrust D at rest D on swallow D during speech D not observed

o Swallowing & Diet D gastrostomy tube D aspiration risk D adequate chew/swallow

D pureed texture D thickened liquids D coughing observed
D ground texture D spillage D rapid eating/stuffing
D chopped texture D food pocketing D uses adaptive equipment
D mechanical soft D modified health diet:
D adaptive strategies:

o Fluency D adequate D repetitions D blocks

D prolongations D halting D nonverbal
D irregular pauses D' secondary mannerisms:

o Rate of Speech D appropriate D too rapid D labored/slow

D variable D nonverbal D differs for echolalia
D progressively faster D increases for ritual speech
~--~---~-----_.'--~--- -_._­
o Rhythm & Intonation D appropriate D low affecVintent D iacks affect/intent D nonverbal
D robotic D caricature patterns D singsong D equal stress
D prolongs vowels D choppy D changes stress re: meaning _yes _no
D other (describe):

NON-ORAL COMMUNICATION _

o Use of SIgn Language D to communicate D on command Demerging D imitated

D w/phystca] prompt D not stimulable D not needed D w/motor limits

o Meaning of Signs D understands D expresses D none D n/a

o Level of Signs D simple D complex D fingerspelling D non-functional

o Sample Signs

o Two-Dimensional
Expression D independently [J emerging skills D w/signing prompt [] w/PECS
D on command D w/gestural prompts [J facilitated [J unsuccessful
D n/a D w/adaptive equipment D sequence of icons

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o Express Yes/No D head nods D motor signals D eye signal D signs

[J symbols/pictures D vocalization D verbalizes D printed words
I~ accepts vs. rejects item/activity D spells w/alphabet board
D communication device D none or random
o Current System
& Effectiveness

o Fine-Motor Abilities D no limitations D fair D poor D non-functional

o Recommended
Communication
System & Potential

Test Results ---.:... _

Current Communication _
Objectives

Communication Strengths _

Communication _
Wea knesses/Needs

Copyright ((':' 2(l03 LinguiSysterns. Inc. 11

Summary; continued

General Intervention
Strategies

Related Plans
in Other Settings

How Residential &

Day Program Plans
Coordinate

How to Integrate
Communication with
Other Disciplines
(Psych., PT., o.r., Rec.)

Recommendations,
Progress, Referrals
& Medical Necessity

SPEECH·LANGUAGE PATHOLOGIST

EVALUATOR COMPANY PHONE

ADDRESS FAX

Printed in the U.S.A. 23-07-9

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