What best describes the client's current status with us? *

Current Client
Returning Client
New Client
Unsure

Are you completing this form on behalf of an adult client? *

No
Yes

What is your relationship to the adult client? *

Client's First Name *

Client's Last Name *

Client's Date of Birth (Month/Day/Year) *//

Client's Gender

Male
Female
Prefer Not to Answer

The client is seeking the following services: *

Speech-Language Pathology
Occupational Therapy

Client's email address *

Secondary Email Address

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Primary Phone *

Secondary Phone

Primary Spoken Language *

Reason for Referral? *

Please describe the Speech/Language difficulties. *

Have the speech/language difficulties changed since the first recognized? *

Yes
No

MEDICAL HISTORY

Have you been hospitalized in the last 5 years?

Yes
No

Have you experienced a CVA (Stroke)? *

Yes
No

Have you ever suffered a head injury? *

Yes
No

Do you have any difficulties with hearing or vision? *

Yes
No

Do you wear glasses? *

Yes
No

Do you wear hearing aids? *

Yes
No

Do you have any current diagnoses? *

Yes
No

Current Diagnoses (Please include the year diagnosed): *

Have you noticed any changed since initially diagnosed? *

Do you have concerns with your mobility? *

Yes
No

Please describe your mobility concerns: *

Please check off any mobility aids you currently use: *

Have you ever been referred to any of the following specialists: Check all that apply: *

If you've been seen by any of the above specialists, please indicate why in the space below: *

Are you currently taking any prescription medications? *

Yes
No

Have you ever been evaluated by or had treatment with a Speech-Language Pathologist? *

Yes
No

Please describe previous S-LP services received (include the years the services were provided): *

Have you ever been evaluated by or had treatment with an Occupational Therapist? *

Yes
No

Please describe previous OT services received (include the years the services were provided): *

EDUCATIONAL HISTORY

Highest Grade Completed *

List any certificates, degrees, or diplomas attained:

Names of educational institutions attended:

Have you ever had difficulty with any of the following prior to your accident/illness/referral? *

WORK HISTORY

Are you currently employed? *

Yes
No

Are you currently driving? *

Yes
No

Have you had to stop doing any of your previous activities and/or household responsibilities? *

Yes
No

FAMILY HISTORY

Do you have a spouse or guardian? *

Spouse
Guardian
Neither

Do you have any children? *

Yes
No

Please list any specific hobbies, interests, or social activities you enjoy:

Are there any family/friends/co-workers who can support you with your therapy programming? *

Adult Case History Form

MEDICAL HISTORY

EDUCATIONAL HISTORY

WORK HISTORY

FAMILY HISTORY

Thank you for taking the time to fill out our Adult Case History Form