Name:           Date of Birth:

Address:    City/State:

 Zip Code:                    Email:

Occupation:     Business Phone:

Employer:

Referred By:    Phone:

Address:

Family Physician:    Phone:

Address:

Marital Status: Single:      Widowed:      Divorced:     Married:

Spouse's Name:

Children (include names, gender, and ages):
 

Who lives in the home?:

What languages do you speak?:
If more than one, which is your primary language:

What was the highest grade, diploma, or degree earned?:

Describe your speech-language problem?:

What do you think may have caused the problem?:

Has the problem changed since it was first noticed?:

Have you seen any other speech-language specialist? Yes:   No:
Who and when?  What were their conclusions or suggestions?:

Have you seen any other specialist 
(physicians, psychologist, neurologists, etc.)?:      Yes:      No:
If yes, indicate the type of specialist:
When you were seen:
and the specialist's conclusions or suggestions: 
 

Are there any speech, language, or hearing problems in your family?: Yes: No:

Medical History
Provide the approximate ages at which you suffered the following illnesses and conditions:

Adenoidectomy:     Allergies:        Asthma:

Chicken Pox:         Colds:             Convulsions:

Croup:                  Dizziness:          Draining Ear:

Ear Infections:        Encephalitis:      German Measles:

Headaches:               Hearing Loss:     High Fever:

Influenza:                     Mastoiditis:      Measles:   

Meningitis:                     Mumps:            Noise Exposure:

Otosclerosis:                Pneumonia:        Seizures:

Sinusitis:                       Tinnitus:              Tonsillectomy:

Tonsillitis:                      Other:

Do you have any eating or swallowing difficulties?:   Yes:    No:
If yes, describe: 

List all medications you are taking: 

Are you having any negative reactions to these Medications?: Yes:   No:
If yes, describe:

Describe any major surgeries, operations, or hospitalizations (include dates):

Describe any major accidents:

Provide any additional information that might be helpful in the evaluation or remediation process:

Person completing form:
Relationship to client: