Speech Language Pathologists, Nancy L. Foreman and Associates, SPEECH is the WINDOW and MIRROR of the MIND

Slow or stagnant speech development

Consistently hoarse voice

General Case History: Adults - Page 1 of 2

 

** Required Fields

 

** Patient Name:      
Date: 
Address: 
Informant: 
Interviewer: 
Birth Date: 
Sex: 
Referred By: 
** Telephone #: 
** Email Address: 
Occupation: 
Marital Status: 


Spouse Name: 

CONCERNS:

Describe the speech and/or hearing 
problems briefly. Is this the only 
problem? 

HISTORY OF SPEECH PROBLEM/MEDICAL DIAGNOSIS:

Age of Onset: 
Conditions of Onset: 
What attempts have been made 
to treat this problem? 
When? 
Results of this Treatment: 
Describe any circumstances that 
change the symptoms: 
What is the severity of this problem? 
If other, explain: 
Is this problem interfering with your educational, social or vocational plans? 
If so, how? 
Do people have difficulty understanding you when you talk to them?
If so, do you know why? 
Have you ever “lost your voice?” 
If yes, describe circumstances 
and duration: 
Was English your first language? 
Other Languages Spoken: 

MEDICAL HISTORY:

Personal Physician: 
Others: 

Were you late to talk or walk? 

If so, at what age? 
Did you have any speech, language or swallowing problems as a child?: 

Any History of 
(check those that apply):

Excessive Colds
Allergies
Sinus Trouble
Asthma
Sore Throats
Upper Respiratory Infections
Pneumonia
Laryngitis
Thyroid Problems
Swallowing Difficulties
Wet Vocal Quality after Eating/Drinking

 

 

 

 

**  

security code
Enter Security Code:

 


PLEASE BE PATIENT WHILE FORM SUBMITS.
You will be automatically directed to a Web page confirming receipt of page 1 of this form. Click on the link on that page to continue with page 2 of this form.

 

You can also complete page 2 of this form by clicking on the applicable link on the Intake Forms page.