Adult Assessment Form

Adult Assessment Form
Name

First NameLast Name
Birth date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History:
Current Medications
Allergies (Medications, Latex...etc)
Previous clip or release of tongue

MonthDayYear
Date
Has you experienced any of the following?
Speech

Frustration with communicationDifficult to understand by othersDifficultly speaking fastDifficulty getting words outTrouble with soundsSpeech delayStutteringSpeech harder to understand in long sentencesSpeech TherapyMumbling or speaking softly"Baby Talk"
Feeding

Frustration when eatingDifficulty transitioning to solid foods as a babySlow eater (don't finish meals)Graze on food throughout the dayPacking food in cheeks like a chipmunkPicky eater with texturesChoking or gagging on foodSpits out foodOther
If trouble with sounds, which sounds?
If in speech therapy, how long?
If picky with textures, which textures?
Nursing or Bottle-Feeding Issues as a Baby

Painful nursing or shallow latchPoor weight gainReflux or spitting upUnable to hold pacifierMilk dribbled out of mouth / messy eaterPoor SupplyNipple shield required for nursingClicking or smacking noise when eatingCried a lot / colic as babyOther
Sleep issues

Sleep in strange positionsSleeps restlessly (moves a lot)Wakes easily or oftenWakes up tired and not refreshedGrinds teeth while sleepingSleeps with mouth openSnores while sleepingGasps for air or stops breathing (sleep apnea)Other
If snores while sleeping, how often?
Other related issues

Neck or shoulder pain or tensionTMJ Pain, clicking, or poppingHeadaches or migrainesStrong gag reflexMouth open / mouth breathing during the dayTonsils or adenoids removed previouslyEar tubes previously / lots of ear infectionsReflux (medicated or not)Hyperactivity / InattentionConstipationOther
Anything else we need to know?
Physician
Speech Therapist
Who referred you to us?
Should be Empty:

Adult Assessment Form

Has you experienced any of the following?