Adult Case History First Name *Last Name *Date *Age *Email Address *Gender *GenderMaleFemaleOtherRace *RaceCaucasian / WhiteAfrican American / BlackHispanicAsianOtherPerson filling out form *Relationship to Patient *Speech/Language/Hearing/Swallowing/Voice ProblemsEnter the cause of these problems and describe when symptoms were first notedEnter how the cause affect your everyday life?Have these problems changed since first diagnosed? *Have these problems changed since first diagnosed?YesNoFirst diagnosedlist recent hospitalizationslist current medicationsTest(s) Completed: Select all that apply *Test(s) Completed: Select all that applyMRICT ScanENT ImagingChest X-RaySwallow StudyUltrasoundOtherIf you Selecter any of the aboveDo you currently work? *Do you currently work?YesNoEmployment and job dutiesDo you live with other people? *Do you live with other people?YesNoWrite the name(s) and their relationship to youNormal daily activities *Hobbies, special activities, favorite activities *What else would you like for us to know about your Speech/Language/Swallowing/Voice difficulties/fluency problems *Have you had Speech Therapy before? *Have you had Speech Therapy before?YesNoSpeech Therapy - when and where?Additional Comments or Concerns *SUBMIT