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* Participant's Name

* Participant's Age

* Diagnosis

How long the onset is?

Disability identification or (and) certification

N

Y

Can he/she speak?

N0

partial

Yes

Are the limbs completely paralyzed or can they be controlled?

How do he/she communicate with people?

Can recognize family members or doctors?

Yes

Partial

Not sure

有沒有使用電腦或平板的經驗？

Y

N

會使用注音或是其他輸入法嗎？

Y

I don't know

N

others

居住地區

收入戶別

低收戶

中低收戶

一般戶

* Contact Name

* phone

* Phone

* Relationship to Participant

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