Communication Impairment Assessment Questionnaire
Please answer the following questions to help assess communication challenges. Your responses will remain confidential. Choose the option that best reflects your experience.
How often do you experience difficulty expressing your thoughts verbally?
*
Never
Rarely
Sometimes
Often
Always
Please rate the level of difficulty you have understanding spoken language in group settings.
*
No difficulty
1
2
3
4
Extreme difficulty
5
1 is No difficulty, 5 is Extreme difficulty
How confident do you feel when communicating with unfamiliar people?
*
1
2
3
4
5
In which situations do you notice the most communication challenges? (Select all that apply)
*
Phone calls
Face-to-face conversations
Group discussions
Public speaking
Other
Rate your ability to communicate your needs in the following situations:
*
Rows
Very Easy
Easy
Moderate
Difficult
Very Difficult
At home
1
2
3
4
5
At work or school
6
7
8
9
10
With friends
11
12
13
14
15
With strangers
16
17
18
19
20
How much do communication challenges affect your daily life?
*
Not at all
1
2
3
4
A great deal
5
1 is Not at all, 5 is A great deal
Do you use any assistive tools or strategies to support your communication?
*
Yes
No
If yes, please specify the tools or strategies you use.
How motivated are you to improve your communication skills?
*
1
2
3
4
5
Please share any additional comments or specific challenges you would like us to know about.
Submit
Should be Empty: