Name *

First

Last

Preferred Name

(Optional) If you have a nickname, or common name you like to go by instead.

Age

What is your age?

Date of Birth

What is your date of birth?

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone

Secondary Phone

Physician Name

What is the name of your doctor?

Physician Phone

Emergency Contact Name *

First

Last

Emergency Contact Relationship

Emergency Contact Phone

What is your main concern for which you are seeking help from a Speech – Language Pathologist?

How does this problem affect your life?

How much does this problem bother you?

A little
Quite a bit
Very much

What do you think caused these difficulties?

When was the problem first noticed?

Has the problem changed (improved or worsened) since it was first noticed?

Yes
No

If yes, please describe how it changed:

What makes the problem worse?

What makes it better or helps you deal with the problem?

Have you seen a speech pathologist for this problem before?

Yes
No

If Yes, please provide the name of the therapist/ clinic, if you remember:

When did you see the therapist? (approximately)

What did the therapist tell you the problem was?

If you had therapy, was it helpful? Please describe:

Do you have copies of your speech – language pathology reports?

Yes
No
Not applicable

If you do not have the reports, may we contact the therapist/ clinic for copies of the reports?

Yes
No
Not applicable

Do you currently have any medical conditions? Please list:

Have you ever had surgery or been hospitalized?

Yes
No

If Yes, please state the reason(s) and the approximate date(s)

Are you currently taking any medications?

Yes
No

If Yes, please list your medications. If you do not remember the name, state what it is for (e.g., blood pressure medication):

Do you have any allergies? Please list:

Have you had a hearing test?

Yes
No

If Yes, when (approximately)?

What were the results of your hearing test?

Do you have any problems with your vision / eyes? Please describe:

Are you under the care of any specialists (medical doctors or therapists)?

Yes
No

If Yes, please provide details:

What is your main language?

What other languages do you speak?

What is your marital status (optional):

Single
Married
Widowed
Divorced

Spouse’s / Partner’s Name if applicable:

If working, what is your occupation? (If attending school or no longer working, indicate Student or Retired):

Level of education achieved:

If you have children, what are their names, genders, and ages?

Who is currently living at home with you?

Do you have a family history of speech, language, hearing or learning problems?

Yes
No

If Yes, describe:

What are activities, other than work, that you often engage in? (e. g; hobbies, social groups, volunteer work)

Do you have difficulties with – expressing your wants and needs?

Do you have difficulties with – finding the right words, for example names of objects or people)?

Do you have difficulties with – having people understand you?

Do you have difficulties with – understanding other people when they talk?

Do you have difficulties with – remembering things?

Do you have difficulties with – reasoning and problem solving?

Do you have difficulties with – reading or writing?

Do you have difficulties with – using your voice?

Do you have difficulties with – speaking fluently?

Do you have difficulties with – eating, drinking or swallowing?

Do you have difficulties with – drooling?

Do you have difficulties with – using technology to communicate (phone, tablet, computer, communication device)?

Do you have difficulties with – interacting socially with others?

Do you have difficulties with – anything else that you think is relevant?

Do you require assistance with activities of daily living, such as mobility, personal hygiene, household chores, banking, driving, shopping, making phone calls, going to medical appointments?

Yes
No

If Yes, please provide details:

What would you like to achieve through speech / language therapy?

Is there anyone that can support you with your therapy (e.g, encourage you, help you with speech exercises, or help with technology such as therapy apps on iPad)?

Yes
No
I don’t think I will need help

If Yes, who will be helping you?

Are there any issues (language, religious, health, logistic, cultural, food restrictions, etc.) that your Speech – Language Pathologist should consider when planning therapy?

Yes
No

If Yes, please explain:

Please provide any additional information that may be helpful to the evaluation/treatment process:

Form completed by:

First

Last

Speech Therapy – Adult Case History