Adult Case History Form General Information: Name: Date of Birth:

Adult Case History Form

General Information:

Name: _________________________________________ Date of Birth: _______________________________

Address: _______________________________________ Phone: ____________________________________

City: __________________________________________ Zip: ______________________________________

E-Mail Address: ___________________________________________________________________________

Occupation: ____________________________________ Business Phone: ____________________________

Employer: ________________________________________________________________________________

Referred By: ____________________________________ Phone: ____________________________________

Address: __________________________________________________________________________________

Family Physician: ________________________________ Phone: ____________________________________

Address: __________________________________________________________________________________

Please describe your present family situation. Include persons who are living in your home and their

relationship to you.

Why are you seeking this evaluation?

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

What is the highest grade, diploma, or degree you have earned?

The Pauline K. Winkler

Speech-Language-Hearing Center

The College of Saint Rose

432 Western Avenue

Albany, NY 12203

(518) 454-5263 / Fax: (518) 337-2313

Director of Clinical Services, Jacqueline Klein, M.A., CCC-SLP

Winkler Center Coordinator, Barbara Hoffman, CCC-SLP

Coordinator of Early Intervention & Preschool Services,

Colleen Fluman, M.Ed.., CCC-SLP

Insurance Coordinator, Melissa Spring, M.S., CCC-SLP

How would you describe your speech-language difficulty?

Who first raised a concern about your speech-language abilities? When was the concern first raised? What was

the concern?

What do you think may have caused this problem?

Has there been any change in your speech or language since the concern was raised? If so, please describe.

Describe any techniques you use that assist you in compensating for the concerns you have.

Have you seen any other speech-language specialists? Who and when? What were their conclusions or

suggestions?

Please describe any remarkable developmental history you feel may be relevant.

Are there any other speech, language, learning or hearing concerns in your family? If yes, please describe.

How do your communication skills affect your job performance?

How successful are you at getting your message across? Please indicate with a check mark.

____ Not Successful ____Fairly Successful ____ Very Successful

Please explain.

How would you describe your comfort level speaking in social situations? Please indicate with a check mark.

____ Uncomfortable ____ Fairly Comfortable ____ Very Comfortable

Please explain.

Describe your ability to respond to sound. Please indicate with a check mark.

____ respond best to loud sounds

____ difficulty hearing in noisy situations

____ no problem hearing in a variety of environments

____ my ability to respond to sounds has decreased in the last few years

Medical History:

Please describe any medical history you feel may be relevant.

Indicate with a check mark if you have had any of the following illnesses and conditions in the past or present:

Adenoidectomy: _______________ Allergies: ____________________ Asthma: _______________________

Cancer: ______________________ Colds: _______________________ Dizziness: _____________________

Draining ear: _________________ Emphyzema: __________________ Ear Infections: __________________

Encephalitis: _________________ Head Injury: ___________________ Heart Disease: _________________

Headaches: __________________ Hearing Loss: __________________ High Fever: ___________________

Influenza: ___________________ Lyme Disease: _________________ Mastoiditis: ___________________

Meningitis: __________________ Noise Exposure: _______________ Otosclerosis: ___________________

Pneumonia: __________________ Seizures: _____________________ Sinusitis: _____________________

Stroke: ______________________ Tinnitus (ringing in the ears): __________________________________

Tonsillectomy: ________________ Tonsillitis: ___________________ Other: ________________________

Have you had any major surgeries? ____ Yes _____No

If yes, what type and when?

Describe any major accidents or hospitalizations.

Have you ever had any negative reactions to medications? ____ Yes ____ No

If yes, please identify and describe.

Educational History:

Please provide any educational history, concerns or problems you have that you feel may be relevant.

Additional Information:

Please provide any additional information you feel may be relevant in helping us to understand your

communication issues or needs.

What changes would you like to see in your communication skills within 1 year? Within 3 years?

I have audiotapes and/or videotapes that are representative of my strengths and/or needs that may provide

additional information regarding my communication skills that I am willing to share. ____ Yes ____ No

Person completing this form: ________________________________________________________________

Signature: ____________________________________________ Date: ______________________________

Rev. 05/2011