Adult Case History

First Name *

Last Name *

Date *

Age *

Email Address *

Gender *GenderMaleFemaleOther

Race *RaceCaucasian / WhiteAfrican American / BlackHispanicAsianOther

Person filling out form *

Relationship to Patient *

Speech/Language/Hearing/Swallowing/Voice Problems

Enter the cause of these problems and describe when symptoms were first noted

Enter how the cause affect your everyday life?

Have these problems changed since first diagnosed? *Have these problems changed since first diagnosed?YesNo

First diagnosed

list recent hospitalizations

list current medications

Test(s) Completed: Select all that apply *Test(s) Completed: Select all that applyMRICT ScanENT ImagingChest X-RaySwallow StudyUltrasoundOther

If you Selecter any of the above

Do you currently work? *Do you currently work?YesNo

Employment and job duties

Do you live with other people? *Do you live with other people?YesNo

Write the name(s) and their relationship to you

Normal 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?YesNo

Speech Therapy - when and where?

Additional Comments or Concerns *

SUBMIT