ASHA Demographic Section Identifying Information Client ID Number Client :Last Name First Name Middle Name Date of Birth (mm/dd/yy) Gender (check one) Ethnicity Race Reading/Writing Premorbid Basic Reading Ability (e.g., able to read newspaper) Premorbid Basic Writing Ability (e.g., able to write notes and complete standard forms) Premorbid Handedness Employment Premorbid Vocational Status Site Information Date of Evaluation (mm/dd/yy) Examiner (last Name, first Name) Evaluation Type Level of Care If Other (explain) If Inpatient Care: Subacute Care? Client Information Living Arrangement (when not in health care setting) Wears Hearing Aid(s) Wears Glasses/Contacts Primary Communication Modality Currently Writes with Dominant Hand Education Completed Functional Assessment of Communication Skills for Adults