Are you filing this form on behalf of an Adult? *

No
Yes

Client's First Name *

Client's Last Name *

Client's Date of Birth *//

Client's 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. *

Has the Speech?Language problem changed since the first diagnosis?

Yes
No

HOSPITALIZATION

Have you been hospitalized in the last 5 years?

Yes
No

Do you have any difficulties eating or drinking? *

Yes
No

PREVIOUS MEDICAL HISTORY: Check all that apply:

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

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 provide the reason and results:

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

EDUCATIONAL HISTORY

Highest Grade Completed

List Certificates Diplomas, or Degrees Attained:

Names of 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? *

No
Spouse
Guardian

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 Speech-Language Programming?

Adult Case History Form

HOSPITALIZATION

EDUCATIONAL HISTORY

WORK HISTORY

FAMILY HISTORY

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