Occupational Therapy For Kids
Feeding Therapy For Kids
Speech Therapy For Kids
OT for Seniors
Assessment for Home Modifications
Recovery After A Stroke
Speech Therapy – Adult Case History
(Optional) If you have a nickname, or common name you like to go by instead.
What is your age?
Date of Birth
What is your date of birth?
Address Line 1
Address Line 2
State / Province / Region
Antigua and Barbuda
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
British Indian Ocean Territory
Central African Republic
Cocos (Keeling) Islands
Congo (Democratic Republic of the)
Eswatini (Kingdom of)
Falkland Islands (Malvinas)
French Southern Territories
Heard Island and McDonald Islands
Iran (Islamic Republic of)
Ireland (Republic of)
Isle of Man
Korea (Democratic People's Republic of)
Korea (Republic of)
Lao People's Democratic Republic
Micronesia (Federated States of)
Moldova (Republic of)
North Macedonia (Republic of)
Northern Mariana Islands
Palestine (State of)
Papua New Guinea
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Sint Maarten (Dutch part)
South Georgia and the South Sandwich Islands
Svalbard and Jan Mayen
Syrian Arab Republic
Taiwan, Republic of China
Tanzania (United Republic of)
Trinidad and Tobago
Turks and Caicos Islands
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Vatican City State
Venezuela (Bolivarian Republic of)
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
What is the name of your doctor?
Emergency Contact Name
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?
Quite a bit
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?
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?
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?
If you do not have the reports, may we contact the therapist/ clinic for copies of the reports?
Do you currently have any medical conditions? Please list:
Have you ever had surgery or been hospitalized?
If Yes, please state the reason(s) and the approximate date(s)
Are you currently taking any medications?
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?
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)?
If Yes, please provide details:
What is your main language?
What other languages do you speak?
What is your marital status (optional):
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?
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?
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)?
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?
If Yes, please explain:
Please provide any additional information that may be helpful to the evaluation/treatment process:
Form completed by: