Adult Intake Form – Progressive Speech Unlimited, LLC

Adult Intake Form / History

Today’s Date:

Client Name:

Nickname:

Date of Birth:

Age:

Pronouns:

Diagnosis (if known):

Address:

City, State, Zip:

Phone #1:

Cell Home Work Other

Phone #2:

Cell Home Work Other

Phone #3:

Cell Home Work Other

Email #1:

Email #2:

Marital Status:

Single Married Widowed Divorced

If under 18, name of parent/guardian:

Name of Spouse or Closest Relative:

Permission to Contact:

Yes No

Contact Information:

Others Living In the Home:

Are you receiving any assistance in the home?

Yes No

If so, please describe:

Language(s) Spoken:

Are you currently driving?

Yes No

Client’s Physician:

Physician Phone Number:

Physician Address:

Other Physicians / Specialists Involved In Care:

Referring Physician:

Phone Number:

Physician Address:

Secondary Physician:

Phone Number:

Physician Address:

Occupation:

Employed Retired Unemployed

How did you hear about us?

Current Status

Please describe your present issue:

Is your communication difficulty related to your work?

Yes No

Is your communication difficulty related to an accident?

Yes No

Date of occurrence:

Please describe:

Briefly describe why you’re seeking an evaluation by a speech-language pathologist at this time:

What do you think caused your speech problem?

What are you expecting out of this evaluation / meeting?

Have you ever had a previous speech, language or feeding evaluation / treatment?

Yes No

By whom:

When:

Describe the results:

Are you currently working with another provider?

Yes No

Provider Name:

Contact Information:

Location:

Has the problem improved or gotten worse? Describe:

When did you first notice the problem?

How does your communication difficulties impact your life, social, work, hobbies, etc.?

What strategies do you use to help cope with this problem?

Does anyone in your family have a history of the same (or different) communication difficulty?

Background & History

Describe any pertinent information regarding your medical history (birth injuries, abnormalities, surgeries, diagnoses, etc.) as well as when they were diagnosed and by whom:

Have you ever had surgery for a related issue?

Yes No

If so, please describe:

Have you ever been hospitalized for a related issue?

Yes No

If so, please describe:

Have you ever been in a serious accident?

Yes No

If so, please describe:

Do you have a chronic illness?

Yes No

If so, please describe:

Are you currently on any medications?

Yes No

Please list medication name and reason for medication:

Medication #1:

Reason:

Medication #2:

Reason:

Medication #3:

Reason:

Medication #4:

Reason:

Do you have any physical disabilities?

Yes No

If so, please describe:

Do you currently use any equipment? (communication device, walker, etc.)

Yes No

If so, please describe:

Please describe any of the selected above:

Have you ever been evaluated by the following specialties?

If yes, please describe the nature of the evaluation and any results:

Educational Background:

If so, please describe:

Are there any questions you would like us to answer for you?

Is there anything else that is important for us to know about you?

Person filling out the form:

Relationship to the client:

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