Adult fluency voice OMD questionnaire

Sunbreak Therapy Services
In order to provide you with the best service and to keep time spent in evaluation to a minimum, please provide the following information. Not all information will apply to you. Also, please provide any additional copies of test administered elsewhere or other information that you feel might be relevant. Thank you.
Date

MonthDayYear
Date
Name

First NameLast Name
Birthdate

MonthDayYear
Date
Age
Legal Guardian(s) Name(s)

First NameLast Name
Address
Day Phone
Format: (000) 000-0000.
Client Occupation
Have other siblings or family members experienced speech/language difficulties? If so, whom:
What language(s) is/are spoken in the home?
In case of emergency, notify
Physician name
Physician Phone Number
Format: (000) 000-0000.
Dentist name
Dentist Phone Number
Format: (000) 000-0000.
Orthodontist name
Orthodontist Phone Number
Format: (000) 000-0000.
Other Therapist name
Other Therapist Phone Number
Format: (000) 000-0000.
Other Doctor name
Other Doctor Name & Phone Number
Format: (000) 000-0000.
Referred by?
Statement of Problem
Describe your speech/language/auditory/orthodontic problem:
When was the problem first noticed?
What strategies have been used at home that seem to help?
What professional services have you received?
Speech, Language and Hearing History:
Did you receive speech-language therapy as a child?
If yes, for what and how long?
Has speech/language been tested in the last 6 months?
By Whom?
Has hearing been tested in the past year?
By whom?
Has vision been tested in the past year?
By whom?
Social Behavior:
Is it difficult or uncomfortable for you to

Make eye contactMake requestsRespond on topicApologizeProtestInterrupt appropriatelyShow humorStay on topicTell you the names of thingsSolve problems verballyTell you how things are usedGreet peopleDescribe things and actionsHave sensitivity to touchAsk for informationHave sensitivity to soundGive informationOther
Medical History:

Below are a list of conditions. I you have had one of the conditions below in your past please put the age next to the condition mark the severity next to it on a scale of 1 to 5. 1 being the lest sever and 5 being extremely sever.

Rows	Age	1	2	3	4	5
Tonsillitis
Tonsillectomy
Adenoidectomy
Lingual Frenectomy
Middle Ear Infections
Earaches
Ear Surgery
Hearing Loss
High Fevers
Measles
Mumps
Pneumonia
Frequent Colds
Upper Respiratory Infections
Snoring
Allergies
Asthma
Sinus Problems
Headaches
Seizures
Head Injury
Loss of consciousness
GERD (Acid Reflux)
Visual Difficulty

Are you currently under a physician's care? For?
Are you taking any medications?
Other medical conditions not mentioned?
Is there smoking in the home?
Is general health good?
Dental History:
Have you ever sucked thumb/fingers?
Until what age?
Did you use a pacifier?
Until what age?
Were baby teeth normal?
Were baby teeth lost at normal ages?
Were baby teeth lost to accident or injury?
If yes, how?
Do you have cavities or periodontal disease?
How often do you brush your teeth?
Flossing per week
Does anyone in your family have similar dental conditions?
Do you clench or grind teeth at night?
Do you clench or grind teeth during the day?
Do you have any pain or clicking upon closing the mouth?
Do you have any pain or clicking when you open your mouth wide?
Do you have any pain or clicking while chewing?
Any other facial pain?
Do you have difficulty chewing, eating and/or swallowing food?
Do you often have headaches?
Any severe facial injuries?
Have permanent teeth been injured/chipped/lost?
Which teeth and when?
Do you have extra teeth?
If you have seen an orthodontist, what has been done so far?
Any orthodontic appliances currently in place?
Are adjustments still being made?
When will appliance come off?

MonthDayYear
Date
What does the orthodontist plan to do in the future? When?
If orthodontic treatment is completed, how long were braces worn?
How long ago were the braces removed?
What kind of retainer is worn?
What other family members had orthodontic treatment?
Has occlusion gotten better, worse, or stayed the same during the last 6-12 months?
Have other family members had oromyofunctional treatment?
Associated Oral Behaviors:
Do you breathe through mouth, nose, or both?
Is mouth open or closed while watching TV, riding in care, or sleeping?
Do you bite your fingernails?
Do you chew on pencils, shirt, etc.?
Do you lick your lips excessively?
Are lips chapped much of the time?
Do you prop your chin on palm or fist?
Do you chew gum excessively?
Educational Information:
School
Grade
Address
Teacher's Name
Did you excel in any subjects/areas?
Did you struggle in any subjects/areas?
Did you read at grade level?
Do you enjoy reading?
Did you spell at grade level?
Do you enjoy writing?
How did you feel about school and your teachers?
Have you been in any special programs (Speech, Language, Reading, Special Education, etc)?
If so, Teacher's/SLP Name(s)
Other Factors/Family History:
If you were to indicate factors that may be related to your problem, which ones would you include? Check as many factors as you think are important.

Anxiety/NervousnessInconsistency in ParentingAutismLack of PlaymatesBehavior ProblemsIntellectual DisabilityBirth Injury/TraumaNeglect by FatherBrain InjuryNeglect by MotherCerebral PalsyOverprotection by FatherDifficulties with AttentionOverprotection by MotherShynessEmotionalEnvironmental ProblemsSibling RivalryEpilepsySlow DevelopmentStubbornnessFamily TraumaVisual DisturbancesFeeding ProblemsRecent MoveGenetics/HeredityHearing LossSensory Integration
Questions & Additional Information:
Are there specific questions you would like answered about your treatment?
Is there anything else about yourself, and/or your family that I should know that might help me provide better service?
Thank you for taking the time to fill out this questionnaire!
Should be Empty:

Sunbreak Therapy Services

Medical History:

Dental History: