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 2 of 2

 

** Required Fields

 

** Patient Name:      
** Email Address:      
Date: 

Please list below all illnesses, injuries and operations. You may list up to six.

 

1) Type:   Age:   Fever?
    Complications:   Treatments:
    Physician:

 

2) Type:   Age:   Fever?
    Complications:   Treatments:
    Physician:

 

3) Type:   Age:   Fever?
    Complications:   Treatments:
    Physician:

 

4) Type:   Age:   Fever?
    Complications:   Treatments:
    Physician:

 

5) Type:   Age:   Fever?
    Complications:   Treatments:
    Physician:

 

6) Type:   Age:   Fever?
    Complications:   Treatments:
    Physician:

 

Present Height:      
Weight: 
Tonsils and Adenoids: 


List all Present Physical Disabilities: 
Current Medications and Purposes: 
Estimate of your Current 
Physical Health: 
Has your vision ever been tested? 
Do you wear glasses? 
Do you think you may have 
a vision problem? 
Has your hearing ever been tested? 
Do you wear a hearing aid? 
Do you think you may have 
a hearing problem? 

SCHOOL HISTORY:

Educational Level 
(check those that apply):

Elementary
Junior High
Senior High
College
Degree
Vocational
Other
If other above, explain: 

SOCIAL HISTORY:

Hobbies: 
Sports: 
Leisure Time Activities: 
Group Memberships: 

FAMILY HISTORY:

Is there any family history of chronic illness, allergies, speech problems, hearing problems, swallowing
problems, or other conditions? Please list all below and describe conditions. 
 

DESCRIPTION OF SPEECH AND/OR HEARING PROBLEM:

Check any of the following which describes your problem:
Often Hoarse
Voice is High Pitched
Low Pitched
Too Loud
Lacks Volume
Fast Rate
Slow Rate
Sounds Gravelly
Hesitant
Voice Tires Easily
Voice Breaks
“Lump in the Throat” Feeling
Mispronunciation
Difficult to Understand when You Talk
Difficult to Understand Others' Speech
Stuttering
Other
If other above, explain: 
Has anyone ever looked at 
your vocal chords and/or soft palate? 
What did they find? 
Have you ever had a 
modified barium swallow test? 
What were the results? 
Additional Comments: 

 

 

 

 

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