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Client’s Name: Todays Date: Spouse Name: Physician:DOB: Date of injury: Email:Address: Phone Number: Medical Diagnosis:Speech Diagnosis:Primary Concerns:Emergency Contact: _____________________________________________________Phone Number: _________________________________________________________Medical HistoryGeneral Health: GoodOften SickMedically FragileHearing Assessed? Yes No Results: Vision Assessed? Yes No Results: Specific Medical event leading to request for speech and language therapy? Yes NoIf yes, describe: Date of injury/medical event:Age of injury/medical event: Hospitalizations?Surgeries?Feeding/Swallowing status at time of event (oral, NPO): Other relevant medical history/conditions?*List current medications and what the meds are addressing:1. 2. 3. Prior Level of FunctionOccupation: Level of Education:Was able to live independently and take care of self? Yes No, if no please describeCurrent StatusAble to work if previously working? Yes No, if no please describeAble to drive: Yes No Ambulatory Status (walks w/o assistance, uses cane, wheelchair, etc)Paralysis/paresis? Yes No Describe: Communication status: Gestures Writing Communication board Speech Generating DeviceVerbal Communication: Sounds Single words Sentences Conversation Writing abilities: letters words sentences paragraphs picturesDoes the client ever get frustrated trying to communicate? Yes No Do communication partners have difficulty understanding client? Yes No Feeding/Swallowing status: Oral FeedingTube Feeding Hobbies/Interests: Therapy HistoryPast Therapy:NameType of therapyNameType of therapyCurrent Therapy:1. NameType of therapy/ How often seen2. NameType of therapy/ How often seenFamily/Caregiver goals of therapy ___________________________________________Client goals of therapy_____________________________________________________Additional info:Thank you for completely filling out this form. Please bring it with you to your appointment or you can email it to margaretbourne@ ................
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