*Name of Patient         Date

*Date of Birth                     Age                Sex  ---Select--- Male Female

Address Line 1

Street

City

State  <--Select--> Outside US and Canada Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Washington DC American Samoa Guam Northern Mariana Is Palau Virgin Islands Armed Forces Americas Armed Forces Europe Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory

Zip

Name of person completing form

Relation to patient

Highest level of education completed     ----Select---- High School College Graduate School Post-graduate school

Occupational History

Hobbies/Interests

Primary Language

Secondary Language(s)

Handedness (Select one)     ----Select---- Right Left Ambidextrous

Did/Do you suffer any of the following? (Check all that is applicable)

CVA/Stroke	Spinal Cord Injury	Head Trauma
Amyotrophic Lateral Sclerosis	Tumor	Myasthenia Gravis
Multiple Sclerosis	Muscular Dystrophy	Parkinson’s Disease
Dystonia	Cerebral Palsy	Alzheimer’s Disease
Rheumatoid Arthritis	Pulmonary Disease	Other

If yes, explain.

If you suffered injury to the brain, where did the damage occur?

Right side                Left side                   Brainstem                        Other   If yes, explain.

Do you have any weakness or paralysis of any part of the body? If yes, where?

Hospitalizations (please state reason hospitalized, date, and length of stay):

Have you undergone any surgical procedures? If yes, explain.

What medications are you currently taking?

                                                                                                                                                         

Do you have difficulty with any of the following? (Check all that is applicable)

Speech	Word finding	Memory	Forming sentences
Writing	Depression	Reasoning	Following instructions
Drooling	Swallowing	Voice	Understanding what others say
Fluency	Attention	Confusion	Putting thoughts into words
Vision	Hearing	Reading	Reading comprehension
Tremor	Weakness	Anxiety	Being understood

Briefly describe the difficulties you are having in the checked areas

What is your current primary communication modality? (Check all that is applicable)

Speaking       Gesture/Sign       Writing/Typing       Communication device (specify)

Have you had speech-language therapy in the past?   If yes, when? Why?

Are you currently receiving occupational or physical therapy?      ---Select--- Yes No

Do you currently live alone?    ---Select--- Yes No

If you live with someone, do they work outside of the home?     ---Select--- Yes No

On average, how many hours are you currently alone per day?

Do you need assistance with any of the following?

Dressing	Bathing	Toileting	Eating
Using the telephone	Walking	Cooking	Driving
Other

Do you have any sleeping problems?  If yes, explain

What is your greatest frustration related to communication?

If the clinician determines that speech-language therapy is indicated, what are your expectations?

(e.g. What skills do you hope to improve and what activities do you hope to return to with therapy?)

Please use the space below to provide additional information.

Word Verification

Type the characters you see in the picture below: Note : This information is confidential and intended only for use by Speech Pathways, P.C. personnel.