Adult Case History Form

Name of person completing this form.*
Email Address*
Client Name (Last, First, Middle)*
Date of Birth and Age*
Sex*
- Male
- Female
Please indicate the primary concern about your speech and language skills.*
Primary Care Physician:*
Any medical diagnosis? Yes or No (If "Yes" please list below.)*
Please explain any other significant medical treatment and/or surgeries.
List any prescribed medications.
Have you had an audiological evaluation (hearing test)? Yes or No (If you respond "Yes" please list when and where it took place and the result.)*
Have you had any Speech and Language testing? Yes or No (If "Yes" what were the results and where did the testing take place?)*
Please feel free to indicate any questions or concerns that you would like to specifically discuss at your initial appointment.*
Please indicate how you heard about our services:*
- Internet Search
- Physician Referral
- Other
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