Adult Intake
Demographics
Name
First Name
Last Name
Today's date:
-
Month
-
Day
Year
Date
Date of birth
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone number:
Please enter a valid phone number.
Are you receiving any assistance in the home
yes
no
If yes, please explain
Are you currently driving
Yes
No
Please list client's Physicians/specialists involved in care
Occupation
Employed
Retired
Unemployed
Student
other
Occupation
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Medical History
List medical diagnosis:
List any surgeries related to issue:
Please list medications:
Any recent hospitalizations?
yes
no
Please describe why you are seeking an evaluation with a speech-language pathologist:
Have you had previous speech therapy services?
yes
no
If yes, please describe:
Hearing loss?
yes
no
If yes, please describe:
Vision deficits?
yes
no
If yes, please describe:
Please list any known allergies:
Have you had evaluations/treatment with any of the following specialists:
Neurology
Psychiatrist/phycologist
gastroenterology
Oncology
Pulinology
Cardiology
Audiologist
Otolaryngologist
Physical Therapist
Occupational Therapist
Is your difficulties related to your work?
Yes
No
Is your difficulties related to an accident
Yes
No
Are you currently using any medical equipment (such as walker, AAC device, ect)
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List surgeries
List all medical diagnosis/chronic health issues
Please tell me any thing else you find would be useful for us to know for this evaluation:
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