Adult Case History Form

Please complete then click the “submit” button prior to initial meeting with clinician. This information will assist in preparing for your evaluation and subsequent services, as necessary.
    Identifying information
 
Name
  Address
  City/State/Zip
  Phone
  Birthdate    Age
        Physician info:
  Name
  Address
  City/State/Zip
  Phone
        Responsible party:
  Name
  Address
  City/State/Zip
  Phone
        Employer:
  Company
  Address
  City/State/Zip
     
    Medical History
     
  Describe your speech/language problems as best you can.
  Have you ever received treatment for this problem? If so, by whom, when, how long?
  Do you have any physical impairment? If so, describe.
  If your problem is the result of or related to an illness, please give the dates of the illness, hospitalization if any, and name of hospital.
  Give a brief description of your illness and any prior medical problems which you feel are related.
  Have you ever had any of the following medical conditions? If so, please explain: High fevers, convulsions, alergies, frequent colds, frequent ear infections, serious injuries, unconsciousness, disorders of the Central Nervious System, cleft lip or palate, other?
 
Tonsils Present Removed
Adenoids Present Removed
     
    Present Health
     
  Are you currently receiving therapeutic services or medical treatment? If so, please explain.
  Present medication(s):
  Medical diagnoses and surgeries:
 
   
Date tested
Is vision normal? Yes No
Is hearing normal? Yes No
Are you...? Left Right handed
 
What is your level of education?