ADULT CASE HISTORY PLEASE PRINT IN INK OR TYPE ALL INFORMATION. Heaing Evaluation. Date of Birth: Gender: Spouse s Name: Spouse s Occupation:
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1 California State University, Fresno Speech, Language and Hearing Clinic 5310 North Campus Drive M/S PH 80 Fresno, California (559) Fax (559) ADULT CASE HISTORY PLEASE PRINT IN INK OR TYPE ALL INFORMATION General Information Today s Date: Please Check One: Aphasia Group Heaing Evaluation Diagnostic Individual Speech Therapy Name: Address: City: Occupation: Employer: Date of Birth: Gender: Zip: Cell Phone: 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:
2 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:
3 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?
4 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.
5 California State University, Fresno Speech, Language and Hearing Clinic 5310 North Campus Drive M/S PH 80 Fresno, CA (559) Fax (559) 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. Client Name 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
6 California State University, Fresno Speech, Language and Hearing Clinic 5310 North Campus Drive M/S PH 80 Fresno, California (559) (559) 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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