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Adult Intake Form
Date Of Birth
Diagnosis (If Known)
City , State , Zip
If Under 18 , Name Of Parent/Guardian
Name Of Spouse or Close Realtive
Permission Of Contact
Others Living In the Home
Are you receiving any assistance in the home?
Are You Currently Driving?
Physician Phone Number
Other Physicians / Specialists Involved In Care
Secondary Physician Number
Secondary Physician Address
How did you hear about us?
Please describe your present issue
Is your communication difficulty related to your Work?
Is your communication difficulty related to your Accident?
Date of Occurence
Briefly describe why you’re seeking an evaluation by a speech-language pathologist at this time
What do you think caused your speech problem?
What are you expecting out of this evaluation / meeting?
Have you ever had a previous speech, language or feeding evaluation / treatment?
Describe the results
Are you currently working with another provider?
Has the problem improved or gotten worse? Describe
When did you first notice the problem?
How does your communication difficulties impact your life, social, work, hobbies, etc.?
What strategies do you use to help cope with this problem?
Does anyone in your family have a history of the same (or different) communication difficulty?
Background & History
Describe any pertinent information regarding your medical history (birth injuries, abnormalities, surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom
Describe your current health status:
Have you ever had surgery for a related issue?
Have you ever been hospitalized for a related issue?
Have you ever been in a serious accident?
Do you have a chronic illness? If so, please describe
Are you currently on any medications? If so, please list medication name and reason for medication
Do you have any physical disabilities?
Do you currently use any equipment? (communication device, walker, etc.) Describe
Check and describe all that apply
Attention Deficit Disorder
Stroke / TIA
Have you ever been evaluated by the following specialties? Check all that apply
If yes, please describe the nature of the evaluation and any results
Highest grade completed
Name of Institution(s)
During school, did you have any problems with the following? Check all that apply
Are there any questions you would like us to answer for you?
Is there anything else that is important for us to know about you?
Person filling out the form
Relationship to the client
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