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Run: Aphasia Assessment Documentation

Aphasia Assessment Documentation template for recording expressive and receptive language findings, naming, comprehension, and functional communication in on...

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Assessment Details

Assessment Date (required)

Assessment Type (required)

Standardized Aphasia Test Used (required)

Enter the test name and version used for scoring and interpretation.

Test Language (required)

Other Test Language (required)

Reason for Referral

Briefly document the clinical reason for the aphasia assessment.

Communication History

Primary Medical Diagnosis

Examples: stroke, traumatic brain injury, tumor, neurodegenerative condition.

Onset Date

Prior Speech-Language Therapy (required)

Current Communication Supports

Hearing or Vision Factors Affecting Testing

Document any sensory or environmental factors that may influence test performance.

Expressive Language

Verbal Output Level (required)

Word-Finding Difficulty (required)

Confrontation Naming Accuracy (%)

Repetition Performance

Expressive Language Notes

Document paraphasias, perseveration, apraxia of speech, circumlocution, and other observable findings.

Receptive Language

Auditory Comprehension Level (required)

One-Step Command Following

Two-Step Command Following

Yes/No Reliability

Receptive Language Notes

Include comprehension breakdowns, need for repetition, cueing level, and response accuracy.

Reading, Writing, and Functional Communication

Reading Comprehension

Writing Ability

Functional Communication in Daily Tasks (required)

Effective Communication Strategies

Functional Communication Notes

Document how the impairment affects participation, safety, and daily communication.

Clinical Impression, Goals, and Submission

Overall Aphasia Severity (required)

Clinical Impression (required)

Summarize the aphasia profile, key strengths, and primary limitations.

Initial Therapy Goals

Document measurable goals or target areas for treatment planning.

Consent / Disclosure Acknowledgment (required)

Use minimum necessary information and avoid collecting PII that is not needed for care.

Yes No N/A

Submission Notes

Optional additional notes for the reviewer. After submission, the record will be available for clinical review and audit trail tracking.

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