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-4572000Harmonize for Speech, Hearing & Language ClinicAdult Speech-Language Intake Form-457200478790Name: __________________________________Address: ________________________________________________________________________________(street)(city)(postal code)Home phone: ____________________Work phone: ____________________Cell phone: ____________________Email: ____________________Past/present occupation: ____________________Highest level of education completed: ____________________Native language: ____________________Other languages spoken: ____________________Emergency contact name and relationship: ____________________ Phone: ____________________ 00Name: __________________________________Address: ________________________________________________________________________________(street)(city)(postal code)Home phone: ____________________Work phone: ____________________Cell phone: ____________________Email: ____________________Past/present occupation: ____________________Highest level of education completed: ____________________Native language: ____________________Other languages spoken: ____________________Emergency contact name and relationship: ____________________ Phone: ____________________ Do you need help filling out this form? Yes NoToday’s Date: _______________________-4572003264535Family Physician’s name: ____________________Phone: ____________________Medical History (Related to the Communication Difficulty)Date of occurrence for difficulty/injury/illness: _________________________________________________Cause of difficulty/injury/illness (accident, stroke, disease): _______________________________________Please list any medications you are currently taking: ___________________________________________________________________________________________________________________________________Please list any allergies: ____________________________________________________________________Do you have any medical concerns? (Ex. seizures, epilepsy, paralysis, migraines): ___________________________________________________________________________________________________________________________________________________________________________________________________00Family Physician’s name: ____________________Phone: ____________________Medical History (Related to the Communication Difficulty)Date of occurrence for difficulty/injury/illness: _________________________________________________Cause of difficulty/injury/illness (accident, stroke, disease): _______________________________________Please list any medications you are currently taking: ___________________________________________________________________________________________________________________________________Please list any allergies: ____________________________________________________________________Do you have any medical concerns? (Ex. seizures, epilepsy, paralysis, migraines): ___________________________________________________________________________________________________________________________________________________________________________________________________-452120-392430Have you had a speech-language assessment? Yes NoIf yes, where and when? _____________________________________________________________Have you had previous speech language therapy? Yes NoIf yes, where and when? _____________________________________________________________What is the nature of your communication difficulty? Stuttering Conversation Reading/Writing Understanding Other ________________________________________________________________________________Are there or have there ever been any feeding problems? Swallowing Drooling Chewing Coughing Choking Using a straw Other ________________________________________________________________________________How do you usually communicate? Gestures Single words Short phrases Sentences No problemsWhich is your dominant hand? (for writing, holding a fork, etc.) Left Right00Have you had a speech-language assessment? Yes NoIf yes, where and when? _____________________________________________________________Have you had previous speech language therapy? Yes NoIf yes, where and when? _____________________________________________________________What is the nature of your communication difficulty? Stuttering Conversation Reading/Writing Understanding Other ________________________________________________________________________________Are there or have there ever been any feeding problems? Swallowing Drooling Chewing Coughing Choking Using a straw Other ________________________________________________________________________________How do you usually communicate? Gestures Single words Short phrases Sentences No problemsWhich is your dominant hand? (for writing, holding a fork, etc.) Left Right18288001239520 Articulation Swallowing/Feeding Speech Clarity Memory or thinking00 Articulation Swallowing/Feeding Speech Clarity Memory or thinking-4572005412105Have you ever had a hearing test? Yes NoIf yes, where and when? _____________________________________________________________If no, do you have any hearing concerns? _______________________________________________Do you wear a hearing aid? Yes No00Have you ever had a hearing test? Yes NoIf yes, where and when? _____________________________________________________________If no, do you have any hearing concerns? _______________________________________________Do you wear a hearing aid? Yes No-436245250190Do you use any of the following supportive aids? Cane(s) Walker Wheelchair Dentures EyeglassesDo you use any of the following communication aids? Communication device Alphabet/Picture BoardSign language Pen and paper iPad Cell phone Other _________________________00Do you use any of the following supportive aids? Cane(s) Walker Wheelchair Dentures EyeglassesDo you use any of the following communication aids? Communication device Alphabet/Picture BoardSign language Pen and paper iPad Cell phone Other _________________________-4572003657600Have there been any changes in mood, personality, ability to care for self since the occurrence of the difficulty/injury/illness? Yes NoIf yes, please explain: _______________________________________________________________ _________________________________________________________________________________Is there any additional information that would help us better understand the nature of your communication difficulty?______________________________________________________________________________________________________________________________________________________________________________00Have there been any changes in mood, personality, ability to care for self since the occurrence of the difficulty/injury/illness? Yes NoIf yes, please explain: _______________________________________________________________ _________________________________________________________________________________Is there any additional information that would help us better understand the nature of your communication difficulty?______________________________________________________________________________________________________________________________________________________________________________-457200-228600Has your communication difficulty affected your social life? Yes NoIf yes, please explain: _______________________________________________________________ __________________________________________________________________________________________________________________________________________________________________What are your hobbies and interests? Are you part of any group activities? (Example: sports, church, clubs)______________________________________________________________________________________________________________________________________________________________________________What are your preferences in reading material?_______________________________________________________________________________________What are your preferences in TV/entertainment?_______________________________________________________________________________________00Has your communication difficulty affected your social life? Yes NoIf yes, please explain: _______________________________________________________________ __________________________________________________________________________________________________________________________________________________________________What are your hobbies and interests? Are you part of any group activities? (Example: sports, church, clubs)______________________________________________________________________________________________________________________________________________________________________________What are your preferences in reading material?_______________________________________________________________________________________What are your preferences in TV/entertainment?_______________________________________________________________________________________-4572006400800We thank you for your time and the care with which you filled out this form. This intake form will be reviewed by our clinic Speech-Language Pathologist (SLP) and Communicative Disorders Assistant (CDA) student(s) and will be a reference for them in planning your therapy services at our clinic. While we strive to provide all clients with the therapy services that they desire, we would like you to keep two things in mind:1) All clients seeking therapy services at this clinic must have had a formal speech assessment completed prior to starting therapy in this clinic.2) This is a teaching clinic and there will be times during therapy where our CDA students will be receiving direction from our clinic SLP.We appreciate your patronage, and look forward to helping you and your loved ones.The Faculty SLP, CDA students, and Staff of the Harmonize for Speech, Hearing & Language Clinic00We thank you for your time and the care with which you filled out this form. This intake form will be reviewed by our clinic Speech-Language Pathologist (SLP) and Communicative Disorders Assistant (CDA) student(s) and will be a reference for them in planning your therapy services at our clinic. While we strive to provide all clients with the therapy services that they desire, we would like you to keep two things in mind:1) All clients seeking therapy services at this clinic must have had a formal speech assessment completed prior to starting therapy in this clinic.2) This is a teaching clinic and there will be times during therapy where our CDA students will be receiving direction from our clinic SLP.We appreciate your patronage, and look forward to helping you and your loved ones.The Faculty SLP, CDA students, and Staff of the Harmonize for Speech, Hearing & Language Clinic ................
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