Adult Speech Pathology Case History Form
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ADULT SPEECH-LANGUAGE PATHOLOGY
Name: ________________________
HISTORY FORM
Date of Birth: __________________
Person completing form: □Patient □Spouse □Parent/Guardian □Other- Name______________
Address: _____________________________________________________________________________
Telephone: (home) ______________________(work) ____________________(cell) ________________
Email: _______________________________________________________________________________
Physician Name: _______________________________ Physician Phone: ________________________
Referred by:___________________________________________________________________________
Reason for evaluation: __________________________________________________________________
Referral Needed: yes no
Insurance: ______________________________
Policy Number: __________________________
Results will be sent to names/locations listed below if address or faxes are provided
Name
Address or Fax
Phone
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Disclosure of healthcare information will only be provided if authorized by the patient or
legal guardian except for known healthcare providers
______________________________________________________________________________
Name
Relationship to patient
Address
Phone
Fax
______________________________________________________________________________
Name
Relationship to patient
Address
Phone
Fax
I authorize the Department to disclose healthcare information to names above. Valid for one year.
Signature of □Patient □Parent/Guardian __________________________ Date: _____________
Printed name of Parent/Guardian: __________________________________________________
Past Medical History
ADD/ADHD
YES
NO
HIV Positive
YES
NO
AIDS
YES
NO
Hormonal Changes
YES
NO
Allergies
YES
NO
Laryngitis
YES
NO
Asthma
YES
NO
Learning Disability
YES
NO
Back Pain
YES
NO
Mental Retardation
YES
NO
Cancer ___________
YES
NO
Physical Limitations
YES
NO
Cerebral Palsy
YES
NO
Pneumonia/Bronchitis
YES
NO
Dementia
YES
NO
Respiratory Disease
YES
NO
Diabetes
YES
NO
Shortness of breath
YES
NO
Ear Infections
YES
NO
Seizures
YES
NO
Epilepsy
YES
NO
Sinus Problems
YES
NO
Gastric Reflux
YES
NO
Speech/Lang Impairment
YES
NO
Head Injury
YES
NO
Stroke (CVA/TIA)
YES
NO
Hearing Loss
YES
NO
Swallowing Problems
YES
NO
Heart Problems
YES
NO
Tracheostomy tube
YES
NO
Hypertension
YES
NO
Thyroid Disease
YES
NO
High fevers
YES
NO
Visual Impairment
YES
NO
Voice Impairment
YES
NO
Ventilator Dependency
YES
NO
Speech Pathologist’s notes: _____________________________________________________________
_____________________________________________________________________________________
ADULT SPEECH-LANGUAGE PATHOLOGY HISTORY FORM (Page 1 of 2)
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