Fill - Free fillable 7.16.15 Adult Case History California State University, Fresno PDF form

Revised 7.15.15

California State University, Fresno

Speech, Language and Hearing Clinic

5310 North Campus Drive M/S PH 80

Fresno, California 93740-8019

(559) 278-2422  Fax (559) 278-5187

ADULT CASE HISTORY

PLEASE PRINT IN INK OR TYPE ALL INFORMATION

General Information Today’s Date: ___________

Please Check One:

Individual Speech Therapy

Name: ________________________________________________ Date of Birth: _________ Gender: ___

Address: ______________________________________________ Email: ___________________________

City: _________________________________________________ Zip: _____________________________

Occupation: ___________________________________________ Cell Phone: _______________________

Employer: ____________________________________________ Home Phone: _____________________

Please Check One: Single Widowed Divorced

Spouse’s Name: ___________________________ Spouse’s Occupation: ___________________________

Names, ages, and gender of children: __________________________________________________________

__________________________________________________________________________________________

Referred By: __________________________________________ Phone:___________________________

Address: __________________________________________________________________________________

Have you been tested and/or evaluated at this clinic before? ______________________________________

If yes, how long ago was your last visit? _______________________________________________________

Office Use Only:

Date Received: ___________________________________________________________________________

Dates Contacted: _________________________________________________________________________

Aphasia Group

Diagnostic

Heaing Evaluation

Revised 7.15.15

Names and relation of other persons living in home: _____________________________________________

What languages do you speak? _______________________________________________________________

What is your primary language? ______________________________________________________________

Highest grade completed or degree earned? ____________________________________________________

Describe your speech-language or hearing problem: _____________________________________________

__________________________________________________________________________________________

What do you think caused the problem? _______________________________________________________

__________________________________________________________________________________________

When did you first notice the problem? ________________________________________________________

__________________________________________________________________________________________

How has the problem changed since you first noticed it? __________________________________________

__________________________________________________________________________________________

How has your communication problem affected your life? ________________________________________

__________________________________________________________________________________________

List other speech-language specialists or audiologists you have seen and describe their conclusions or

recommendations: __________________________________________________________________________

__________________________________________________________________________________________

Revised 7.15.15

List any other specialists (physicians, psychologists, neurologists, etc.) you have seen, and the specialists’

conclusions or suggestions: __________________________________________________________________

__________________________________________________________________________________________

Describe any other speech, language, learning, or hearing problems in your family: ___________________

__________________________________________________________________________________________

Medical History

General Health is: Good Fair Poor

Provide the approximate ages at which you experienced the following illness and conditions:

Adenoidectomy ______________ Allergies ____________________ Asthma _______________________

Chicken pox _________________ Colds _______________________ Convulsion ____________________

Croup ______________________ Diabetes ____________________ Draining ear ___________________

Ear Infections _______________ Dizziness ____________________ Epilepsy ______________________

Headaches __________________ Encephalitis _________________ German Measles _______________

Influenza ___________________ Hearing Aids ________________ Heart problems ________________

Meningitis __________________ Hearing Loss ________________ High fever ____________________

Numbness ___________________ Mastoiditis __________________ Measles _______________________

Otosclerosis _________________ Mumps _____________________ Noise Exposure ________________

Sinusitis ____________________ Paralysis ____________________ Seizures ______________________

Tonsillitis ___________________ Pneumonia __________________ Tonsillectomy _________________

Ulcers ______________________ Visual Problems _____________ Glasses _______________________

Do you smoke? ______________ How much per day? __________

Revised 7.15.15

List all prescription and nonprescription medication used during the past year: ______________________

__________________________________________________________________________________________

Describe any eating or swallowing difficulties you have experience: ________________________________

__________________________________________________________________________________________

List any major accidents, illnesses, surgeries, or hospitalizations (include dates): _____________________

__________________________________________________________________________________________

Provide any additional information that you might believe to be helpful in the evaluation or remediation

process: __________________________________________________________________________________

__________________________________________________________________________________________

PLEASE ATTACH ANY REPORT YOU HAVE FROM ANOTHER AGENCY, SCHOOL, OR DOCTOR.

Person completing the form: _________________________________________________________________

Relationship to client: _______________________________________________________________________

Signed: _____________________________________________ Date: _____________________________

**Please Note: You must complete and sign the attached Observation and Photo/Video Consent statements and return

them with your case history form. Thank you for taking the time to fill out the forms completely and accurately.

Revised 7.15.15

California State University, Fresno

Speech, Language and Hearing Clinic

5310 North Campus Drive M/S PH 80

Fresno, CA 93740-8019

(559) 278-2422  Fax (559) 278-5187

Observation Consent

Consent is hereby given to faculty, students and other persons approved by the clinical supervisor at the

Language, Speech and Hearing Clinic at California State University, Fresno to observe

_________________________________ in the clinic or in off campus settings.

The purpose of these observations is to train University Communicative Sciences & Disorders students

(both diagnostic and treatment sessions may be observed). Students from other departments studying

children and adults with language, hearing, and speech disorders may also watch and listen if the

supervisor gives permission.

__________________________________________ ______________________________

Parent/Guardian/Self (18 or older) Date

Client Name

Revised 7.15.15

California State University, Fresno

Speech, Language and Hearing Clinic

5310 North Campus Drive M/S PH 80

Fresno, California 93740-8019

(559) 278-2422 (559) 278-5187 fax

Consent and Release for Photographs or Videotaping

Consent is hereby given to the Speech, Language, & Hearing Clinic, at California State

University, Fresno, to take photographs, or videotape of _______________________________. I

understand that the photos/videos will be used to train University students and demonstrate department

activities to the general public (e.g. CDDS department website or on Professional Health Services

building bulletin boards).

I understand that I will be able to view the photographs or videotape if I request to do so.

_______________________________________ _______________________

Parent/Guardian/Self (18 or older) – Print Name Date

_______________________________________

Signature

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