Adult Case History Form Please enable JavaScript in your browser to complete this form.Are you filing this form on behalf of an Adult? *NoYesClient's First Name *Client's Last Name *Client's Date of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Client's email addressAddressAddress Line 1Address Line 2CityState / Province / RegionPostal CodeAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryPrimary Phone *Secondary PhonePrimary Spoken LanguageReason for Referral? *Please describe the Speech/Language difficulties. *Has the Speech?Language problem changed since the first diagnosis?YesNoHOSPITALIZATIONHave you been hospitalized in the last 5 years?YesNoDo you have any difficulties eating or drinking? *YesNoPREVIOUS MEDICAL HISTORY: Check all that apply:HeadachesSeizuresCardiac DifficultiesDizzinessPeg TubeEncephalitisDiabetesHearing LossHypertensionPneumoniaRespiratory IssuesHave you Experienced a CVA (Stroke)? *YesNoHave you ever suffered a head injury? *YesNoDo you have any difficulties with hearing or vision? *YesNoDo you wear glasses? *YesNoDo you wear hearing aids? *YesNoHAVE YOU EVER BEEN REFERRED TO ANY OF THE FOLLOWING SPECIALISTS?: Check all that apply:AudiologistOtolaryngologistPsychologistOccupational TherapistPhysical TherapistNeurologistPsychiatristGastroenterologistIf you've been seen by any of the above specialists, please provide the reason and results:Are you currently taking any prescription medications? *YesNoHave you ever been evaluated by or had treatment with a speech language pathologist? *YesNoEDUCATIONAL HISTORYHighest Grade CompletedSome Elementary SchoolingGrade 8Grade 9Grade 10Grade 11Grade 12Some CollegeCollege DiplomaSome UniversityUniversity DegreeMasters DegreePhDList Certificates Diplomas, or Degrees Attained:Names of Institutions attendedHave you ever had difficulty with any of the following prior to your accident/illness/referral?UnderstandingAttentionReadingMemorySpeakingProblem SolvingWritingMathWORK HISTORYAre you currently employed? *YesNoAre you currently driving? *YesNoHave you had to stop doing any of your previous activities and/or household responsibilities?YesNoFAMILY HISTORYDo you have a spouse or guardian? *NoSpouseGuardianDo you have any children? *YesNoPlease 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?YesNoUnsurePlease provide any additional information you feel may benefit your therapy:SUBSCRIBE to our periodic NEWSBITES for updates, tips & happenings!SubscribeThank you for taking the time to fill out our Adult Case History FormHow did you hear about us?Friends or familyCo-workerfacebooktwitterLinkedinInstagramNews articleRadio/TVWeb search resultsOtherPlease share how you heard about SLNWebsiteSubmit