Adult Speech Therapy Case History

Adult Speech Therapy Case History

Adult speech therapy case history form for clinical intake. Please complete as much as you are able.
Client & Contact Information
Full Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Primary Language
Other Languages
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
Emergency Contact Name
Emergency Contact Relationship and Phone
Referral Information
Referring Provider

First NameMiddle NameLast Name
Reason for Referral
Date of Referral

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Primary Concerns
Main areas of concern

Other
Describe your primary concern(s)
When did these concerns begin?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How have these concerns changed over time?
What are your goals for therapy?
Medical History
Primary Care Provider

First NameMiddle NameLast Name
Current Diagnoses
Past Medical History
Stroke, Brain Injury, or Other Neurological History
Head/Neck Cancer or Radiation History
Relevant Medical History

Other
Current Medications
Medication Effects or Side Effects
Allergies
Hearing, Vision, Sensory
Hearing status
Hearing aids or cochlear implants

Other
Last hearing evaluation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Vision status
Glasses or contact lenses

Other
Visual changes
Sensory concerns
Communication & Cognition
Speech or language concerns
How do communication difficulties affect you emotionally?

Other
Cognitive concerns
Have you ever been diagnosed with any cognitive conditions?

Other
Swallowing & Nutrition
Swallowing Difficulty / Symptoms
Current Diet Texture
Liquid Consistency
History of Aspiration or Pneumonia
Weight Loss or Appetite Changes
Education, Employment, Daily Activities
Highest Education Level
Current Employment Status

Other
Occupation / School Program
How do speech, language, voice, or cognitive concerns affect your work or school performance?
Hobbies, Interests, and Typical Daily Activities
Activities of Daily Living & Independence
Living situation
Level of independence
How these challenges affect daily life
Previous Evaluations/Therapies
Prior SLP/OT/PT/Neuropsych Evaluations and Therapies
Support System & Caregivers
Support Persons / Caregivers
Communication Assistance Needed

Other
Communication Preferences & Goals
Preferred Information Delivery

Other
How do you define a successful outcome for therapy?
Other notes or communication preferences
Should be Empty:

Adult Speech Therapy Case History

Client & Contact Information

Referral Information

Primary Concerns

Medical History

Hearing, Vision, Sensory

Communication & Cognition

Swallowing & Nutrition

Education, Employment, Daily Activities

Activities of Daily Living & Independence

Previous Evaluations/Therapies

Support System & Caregivers

Communication Preferences & Goals