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Home
Services
Adult Services
Swallowing Disorders or Dysphagia
Post-Stroke Rehabilitation
Cognitive-Communication Disorders
Accent Reduction/Modification
Voice Disorders
Pediatric Services
Speech And Language Therapy
Occupational Therapy
Feeding Therapy
Reading/Dyslexia, Auditory Processing, And Listening Skills
Social Skills Groups
Early Intervention
About Us
Our Team
Our Treatment Approach
Forms
Blog
Contact
Patient History – Adult
Home
/
Forms
/ Patient History – Adult
Name
First
Last
Date of Birth
Date Format: MM slash DD slash YYYY
Age
Sex
Male
Female
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Home Phone
Cell Phone
Work or Other Phone:
Email
Marital Status:
Married
Single
Widowed
Race/Ethnicity (select one or more):
American Indian/Alaskan Indian
Black/African American
Native Hawaiian or Other Pacific Islander
Asian
Hispanic/Latino
White
Unknown
Caregiver:
Do you have any children?
Yes
No
If so, is your child your caregiver?
Yes
No
Do you have multiple caregivers?
Yes
No
Emergency Contact:
Name
First
Last
Phone Number
Is this number for:
Home
Cell
Work
Relationship to Patient:
Referral Source:
Primary Insurance:
Policy Holder Name:
Group Number
Phone Number
Secondary Insurance:
Policy Holder Name:
Group Number
Phone Number
Doctor
Counselor/Therapist
Friend
Self
Other
Insurance Information:
Reason for Visit Today
Have you received speech-language pathology services before?
Yes
No
If yes, when?
Where?
Have you received any other therapy services before (rehab, OT, PT)?
Yes
No
If yes, when?
Where?
Medical History:
List illnesses, surgeries, injuries, or medical problems. Please list date and the cause of injury, if any.
Have you experienced any muscle weakness? If so describe this experience:
Have you experienced any hearing/vision problems due to this injury?
Yes
No
If yes, how so?
List medications taken on a regular basis:
List known allergies:
Have you had problems with or changes in (check all that apply):
Hearing:
Wear hearing aid(s)?
Yes
No
Had hearing test?
Yes
No
If yes, when?
Vision:
Wear glasses?
Yes
No
Wear corrective lenses?
Yes
No
Had vision screened?
Yes
No
If yes, when?
Teeth:
Wear dentures?
Yes
No
Breathing:
Swallowing:
Education and Work History
Last grade completed:
Occupation before onset:
Currently working?
Yes
No
Hobbies/Special Interests:
Did you enjoy reading/writing before onset?
Yes
No
Preferred use of hand:
Right
Left
Both
Language(s) Spoken
Is English your primary language?
Yes
No
If no, is an interpreter needed?
Yes
No
If no, what language(s) is/are spoken at home:
If no, what language(s) is/are spoken in your workplace/community:
Communication and Language
Please describe your speech after onset? (Respond in one words, short phrases, repeats others, etc.)
Has your speech changed after onset?
Yes
No
If yes, how did it change?
How do you currently communicate with others? (Verbally, use of gestures, writing, use of AAC, etc.)
How well can you follow directions, following along in conversations, remember items, etc.?
What are your biggest difficulties?
How do you solve/react to these difficulties? (Removal, anxiety, frustration, etc.)
When are you most frustrated with your communication?
Additional Information
What is your current daily routine?
Describe your personality before and after onset?
Were there any changes in mood, personality, self-care, etc?
Tell us about your goals and expectations for therapy:
Is there anything else you’d like for us to know about you?
I am granting permission for Chandler Speech and Language Services to evaluation and provide treatment recommendations as clinically necessary. Attendance is a critical factor with regard to therapy services.
I understand that if I need to cancel my appointment I must do so within 12 hours of the appointment time. If I fail to do so, Chandler Speech and Language has the right to charge a no-show fee of $50.
If I miss 3 consecutive sessions of therapy, Chandler Speech and Language has the right to place services on hold until scheduling may be resolved.
My signature indicates that, to the best of knowledge, all information provided above is accurate and current. My signature indicates I am in agreement with all policies presented above.
I acknowledge that it is my responsibility that if my insurance changes at any time or fails to cover any services, I may be responsible for any remaining balance.
Patient or Parent/Guardian Signature
*
Relationship to Patient
Date
Date Format: MM slash DD slash YYYY
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