Adult Speech and Language Questionnaire Adult Speech and Language Questionnaire Today's Date(Required) Month Day Year Name(Required) First Name(Required) Last Phone(Required)Email(Required) Date of Birth(Required) Month Day Year Person Completing the form, if other than clientNameRelationship to Client Add RemoveClient Occupation(Required) This Occupation is(Required) Current Prior Language spoken in the home(Required) Background InformationWhat is/are your primary concern(s) for this speech, language, voice, and/or swallowing evaluation?(Required)When did you first notice this concern?(Required) Was this related to an accident/injury/illness?(Required) Yes No If yes, please explain (i.e. stroke, TBI, degenerative disease, concussion) or state diagnosis Please list previous speech, language, and/or swallowing intervention(Required)LocationDates/months/years attendedNumber of times/weekLength of session Add RemovePlease upload most recent report or discharge reportMax. file size: 32 MB.What has helped the concern?(Required) What has not helped the concern?(Required) Medical HistoryPlease check all that apply(Required) Hospitalizations Serious illness or accident Seizures Head injuries Headaches Serious infections Other stomach or intestinal issues Cancer or leukemia Effects of stroke Cerebral Palsy Hearing problems Muscular Dystrophy Respiratory issues (e.g. history of pneumonia, ERI) Allergies Parkinson's disease Dementia Multiple Sclerosis Memory Loss Currently under the care of psychologist/psychiatrist Currently under the care of a neurologist Other, not listed For all that you checked in the previous question, please give additional informationDate(s)Name of Care Provider Add RemoveList all current medications (prescription and over the counter)NameDosageReason for taking Add RemoveFamily Information/HistoryPerson(s) living in the same home as you:(Required)NameRelationship Add Remove
