Adult Questionnaire

Confidential Adult Questionnaire

(All information provided is strictly confidential and will not be provided to any other agency without your written consent.)
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Nearest relative we may contact:

First NameLast Name
Phone Number of nearest relative:

Area CodePhone Number
Are you employed:   YES    NO
If yes, where
For how long
If you are unable to work, please indicate why
I. General Information
Describe what concerns you have about your communication:*
When did you first notice this problem:
List any diagnoses you have had has and the professional who made the diagnosis (include dates):
Have you received any previous treatment for this specific problem?

YESNO
If yes, where/when:
Is a second language spoken in the home:

YESNO
If so, what language:
Please list other persons living in your home, their ages, and relationship to child: *
What do you hope to learn from this evaluation and what specific questions do you have or areas do you wish to address? *
II. Medical History
Any surgeries?

YESNO
If yes, explain
Have you experienced any of the following (please check if yes, and indicate when if applicable below):

Strokes/CVACardiac InvolvementHypertensionDiabetesInfectionSeizuresHead InjuryParalysisOther
Please describe any of the above checked items:
III. Educational History
Diplomas or Degrees attainted:
Names of Colleges/Institutions attended:
III. Occupational Status
Occupation:
Currently Employed:   YES
If not, date of last employment:
Type of work?
Amount of communication proficiency required:
VI. Speech-Language
What is your most frequent means of communication:*

gesturessoundswordsphrasescomplete sentenceslooking at objectspointing to objectsphysical manipulation
In what situations is your communication most impacted?
VII. Hearing/Vision
Do you suspect any hearing difficulty? YES    NO
Do you suspect any vision difficulty? YES    NO
Have you been diagnosed with a hearing impairment? YES    NO
IX. Additional Comments
Please provide any additional comments or concerns:
Completed by:
Relationship to Client:
Email
example@example.com
Date

MonthDayYear
Should be Empty:

Confidential Adult Questionnaire

I. General Information

II. Medical History

III. Educational History

III. Occupational Status

VI. Speech-Language

VII. Hearing/Vision

IX. Additional Comments