Language
English (US)
Spanish (Latin America)
Speech Case History Form for Adult Patients
Please fill in the form below if the patient is between the ages of 21 and older.
Adult Patient Information
Please answer each question to the best of your knowledge.
Patient Name
*
First Name
Middle Name
Last Name
Date of Birth
*
Please select a month
January
February
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Month
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Day
Please select a year
2024
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Year
Date of Evaluation
*
-
Year
-
Month
Day
Date
Which location is the patient visiting today?
*
Uptown- 4219 Magnolia Street New Orleans
Elmwood- 5640 Jefferson Hwy Harahan
What is the email address of the provider completing this form?
*
example@example.com
Accompanied by
Please type N/A if there is no additional individual accompanying the patient.
Primary Language Spoken
*
English
Spanish
Vietnamese
Other
Patient Sex
*
Please Select
Male
Female
N/A
Primary Concern for Today's Appointment
*
Hearing
Speech/Language
Both
Medical History
Please answer each question to the best of your knowledge.
Primary Care Physician's Name
First Name
Last Name
Medical History/Symptoms of Concern
Please enter any notes regarding patient's medical history.
Is the patient currently taking any medication?
*
Yes
No
Unsure
If yes, please list it here
Speech- Language History
What is the primary concern regarding the patient's speech/language?
*
Articulation
Onset of Aphasia due to stroke
Fluency
Language/Literacy
Swallowing
None of these
Other
If other, please list the concern below.
Does the patient's speech seem normal? If not, please explain why you do not believe the patient's speech is normal.
*
Before today, has the patient ever received speech therapy services?
Yes
No
Unsure
Does the patient become frustrated when communicating?
Yes
No
Sometimes
Unsure
Is the patient understood by most people?
Yes
No
Sometimes
Unsure
Approximately how many total words does the patient use?
Does the patient have any allergies?
*
Yes
No
Unsure
If yes, please list the patient's allergies below.
Does the patient follow a typical diet? If no, please describe the patient's diet.
Does the patient have difficulty swallowing?
Does the patient have concerns about any of the following?
Hearing Loss
Dizziness
Loss of Balance
Risk for Falls
Public Speaking
Is there anything else that you would like us to know about the patient's speech, hearing, or balance?
Submit
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