Adult Case History Form for Speech/Language Pathology

Steps:

Please fill out this form as completely as possible. The information will help us understand your present communication problem(s) and will aid us in planning appropriate testing procedures. ALL INFORMATION IS STRICTLY CONFIDENTIAL.

*PLEASE NOTE: AFTER COMPLETION, PLEASE RETURN THIS FORM, ALONG WITH ANY OTHER PERTINENT MEDICAL REPORTS (e.g. Hospital discharge summaries, Neurological reports) TO THE CENTER AT LEAST (1) WEEK BEFORE THE SCHEDULED EVALUATION.

Client Information

Client's First Name:	Middle Name:	Last Name:
Permanent Address:	City:	State:	ZIP Code:
Home Phone:	Work Phone:	Cell Phone:	E-Mail:
Date of Birth:	Sex: Male Female	Age:
Marital Status: Single Married Divorced Widowed
Ethinicity: African-American Asian Caucasian Hispanic/Latino Other
Employer:	Employer Phone:
Name of Spouse:
Spouse's Employer:	Employer Phone:
Combined Income: Less than $12,000 $12,000-$20,000 $20,000-$30,000 $30,000-$50,000 $50,000-$70,000 $70,000-$90,000 $90,000-$120,000 Over $120,000
How did you hear about us? Word of mouth Phone Book/Yellow Pages School System Internet Physician - Name: Other
Reason for Referral:
Briefly Describe Problem:

Speech and Hearing History

Please mark if you have a history of difficulty with any of the following:

Symptoms	Never	Rarely	Frequently	Date of Last Incidence
Swallowing (coughing/choking/pain)
Stuttered speech
Expressing Thoughts
Orientation
Judgment
Problem Solving
Maintaining Topic of Conversation
Memory
Focusing/Attending
Following Directions (processing information)
Reading/Writing
Slurred speech
Word Finding

How do others react toward the problem:

Is there a family history of this problem? Please explain:

Have you had previous speech therapy for this current problem? Please explain:

Has this problem improved/deteriorated since the onset? Please explain: