Adult Case History Form - Speech Pathology Solutions

Step 1 of 11

General Information

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Occupation Information

Occupation(Required)

Business Phone(Required)

Referral/Physician Information

Referred By

Referral Phone

Referral Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are your referral and primary physician the same doctor?

Yes

Physician(Required)

Physician Phone(Required)

Physician Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Emergency Contact Information

Referral Name(Required)

First Last

Referral Phone(Required)

Emergency Contact's Relation to Patient(Required)

Referral Name

First Last

Referral Phone

Emergency Contact's Relation to Patient

Personal/Demographic Information

Marital Status(Required)

Single

Married

Widowed

Divorced

Spouse's Name(Required)

First Last

Children (include names and ages)(Required)

Who lives in the home? What Languages are spoken in the home? What is the primary language?(Required)

What was the highest grade, diploma, or degree earned?(Required)

Describe your current or past occupation(Required)

List your hobbies/interests(Required)

Allergies

Any allergies to medications?(Required)

Yes

Please Specify(Required)

Any allergies to food or environment?(Required)

Yes

Please Specify(Required)

Medical History

List any current medications you are taking(Required)

List any major surgeries, accidents, or hospitalizations(Required)

Have you suffered from any of the following illnesses and/or conditions?(Required)

None

Allergies

Asthma

Cancer

CHF

Diabetes

Sleep APNEA

COPD

Dizziness

Draining Ear

Ear Infections

Encephalitis

Headaches

Influenza/COVID О

Mastoiditis

Multiple Sclerosis

Other Neurological Conditions

Parkinson's

Pneumonia

Primary Progressive Aphasia

Seizures

Sinusitis

Stroke

Tinnitus

Tonsilitis

Voice Disorder

Other

Please Specify(Required)

Provide the approximate ages at which you suffered the previous illnesses and/or conditions(Required)

Please specify age(s) for each illness and/or condition.

Do you have a history of smoking?(Required)

Yes

Please specify how long(Required)

Do you currently wear dentures?(Required)

Full

Partial

Do you have a pacemaker or Deep Brain Stimulator?(Required)

Yes

Have you seen any other Speech Language Pathologists?(Required)

Yes

Who and When?(Required)

What were their conclusions or suggestions?(Required)

Have you seen any other specialists (physician, neurologist, audiologist, psychologist, etc.)?(Required)

Yes

What Type and When?(Required)

What were their conclusions or suggestions?(Required)

Have you previously or are you currently being seen by any other rehabilitation professionals?(Required)

Physical Therapy

Occupational Therapy

Other

Please Specify(Required)

Speech Language History

Please select the difficulties that you experience within each "Never, Sometimes, or Always" categories.

Never Experience(Required)

Difficulty speaking

Difficulty with word-finding

Difficulty being understood by others

Difficulty understanding others

Difficulty focusing/maintaining attention

Difficulty remembering things

Difficulty reading

Difficulty writing

Difficulty maintaining topic

Difficulty problem solving

Difficulty following directions

Sometimes Experience(Required)

Difficulty speaking

Difficulty with word-finding

Difficulty being understood by others

Difficulty understanding others

Difficulty focusing/maintaining attention

Difficulty remembering things

Difficulty reading

Difficulty writing

Difficulty maintaining topic

Difficulty problem solving

Difficulty following directions

Always Experience(Required)

Difficulty speaking

Difficulty with word-finding

Difficulty being understood by others

Difficulty understanding others

Difficulty focusing/maintaining attention

Difficulty remembering things

Difficulty reading

Difficulty writing

Difficulty maintaining topic

Difficulty problem solving

Difficulty following directions

If “always” for any of the previous difficulties, please indicate when you first noticed each.

Please specify individually, if applicable.

Swallowing History

Please select the difficulties that you experience within each "Never, Sometimes, or Always" categories.

Never Experience(Required)

Difficulty swallowing solids

Difficulty swallowing liquids

Difficulty chewing food

Watery eyes when eating

Coughing when eating and/or drinking

Avoidance of certain foods/textures/liquids

Sometimes Experience(Required)

Difficulty swallowing solids

Difficulty swallowing liquids

Difficulty chewing food

Watery eyes when eating

Coughing when eating and/or drinking

Avoidance of certain foods/textures/liquids

Always Experience(Required)

Difficulty swallowing solids

Difficulty swallowing liquids

Difficulty chewing food

Watery eyes when eating

Coughing when eating and/or drinking

Avoidance of certain foods/textures/liquids

If “always” for any of the previous difficulties, please indicate when you first noticed each.

Please specify individually, if applicable.

Please select your diet from one of the options below(Required)

Regular Foods

Soft Foods

Puree

Please describe any additional speech-language or swallowing concerns(Required)

*Only for clients who are covered by medicare

Have you received physical therapy this calendar year?

Yes

Permission to be Photographed or Recorded

I give my permission to be photographed or recorded for diagnostic purposes only(Required)

Yes

Please input your initials below(Required)

Today's Date(Required)

YYYY

Person completing form(Required)

First Last

Relationship if not patient

Signature(Required)

Today's Date(Required)

YYYY

General Information

Occupation Information

Referral/Physician Information

Emergency Contact Information

Personal/Demographic Information

Allergies

Medical History

Speech Language History

Swallowing History

*Only for clients who are covered by medicare

Permission to be Photographed or Recorded

Wall

WEST CREEK