Adult Speech Pathology Case History Form Page 2
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Name: ________________________
ADULT SPEECH-LANGUAGE PATHOLOGY HISTORY FORM (Page 2 of 2)
Other Medical History:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Please list any surgeries/medications (and reason for medication):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Significant Family medical history: ________________________________________________________
_____________________________________________________________________________________
Family and Social History:
Occupation: ______________________
Student
Unemployed
Retired
Education:
College
High School
Last year completed: ____________________
Marital Status:
Single
Married
Divorced
Widowed
Children
Yes
NO
Grandchildren
YES
NO
Members of Household: ______________________
Tobacco use:
YES
NO
# of years___________
Packs per day: ____________
Discontinued date: __/___/___
Alcohol intake: YES
NO
# of drinks per week _________
Do you have a substance dependency?
YES
NO
If yes, please explain:____________________________________________________________
Have you ever been examined or treated by the following?
Name/Findings
Ear Nose and Throat Specialist
YES
NO
________________________________
Eye Specialist
YES
NO
________________________________
Neurologist
YES
NO
________________________________
Psychiatrist/Psychologist
YES
NO
________________________________
Speech/Language Pathologist
YES
NO
________________________________
Neuropsychologist
YES
NO
________________________________
Audiologist (Hearing Test)
YES
NO
________________________________
Physical or Occupational Therapist
YES
NO
________________________________
Other_______________________
YES
NO
________________________________
Any other information that you feel would be important for us to know:_______________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Speech Pathologist’s notes: _____________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Speech Pathologist: _________________________
__________ ________ ____________
Signature
ID #
Date
Time
ADULT SPEECH-LANGUAGE PATHOLOGY HISTORY FORM -Page 2 of 2
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