Adult Fluency Case History Form

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Transcription:

Adult Fluency Case History Form Name: Address: Phone: Primary Language: Referred By: Primary Doctor: Phone: Age: Date of Birth: Please describe your speech: What information do you hope to obtain from this evaluation? Do you have trouble with any of the following? Please circle all that apply. Finding the right word Getting to the point Organizing your thoughts What motivated you to seek advice or help regarding your speech? FAMILY HISTORY Is there a family history of stuttering or any other speech, language, learning, reading, attention, or hearing problems? If yes, please describe. Terri Rossman, M.S., CCC, Director Mary Ann Raymond, M.S., CCC, Associate Director 133 Wall Street, Princeton NJ 08540 Tel: 609-924-7080 Fax: 609-924-6563 info@psllcnj.com www.psllcnj.com

Adult Fluency Case History Form Page 2 of 6 MEDICAL HISTORY As far as you know, was your speech and language development normal? Please describe any difficulties: How is your present health? Good Fair Poor Have you ever been hospitalized? Do you have any chronic or current medical problems? If yes please list Are you presently taking medication? If yes, please list FLUENCY PROBLEM A. Onset 1. When was the problem first noticed? 2. By Whom? 3. What do you believe caused the problem? B. Type of Stuttering 1. Please check or describe symptoms which apply to your stuttering: Repetitions of sounds ( I want the b-b-b-all. ) Repetitions of single syllable words ( I-I-I-I want to go. ) Repetitions of syllables ( So-so-so-soldier ) Repetitions of entire words ( I want-want-want the ball. ) Repetitions of phrases ( I want -I want -I want to go. ) Prolongation of sounds ( ssssssssssoldier ) Use of filler words ( um, and then, you know )) Faulty Breathing Describe:

Adult Fluency Case History Form Page 3 of 6 Changes in loudness. Describe: Facial movements. Describe: Hand movements. Describe: Other body movements. Describe Struggle and tension during speech. Describe: Other. Describe: 2. Describe any changes in the problem since it began? 3. If possible, list three situations in which you have noticed the speech problem is worse than usual. a. b. c. 4. If possible, list three situations in which you have noticed the speech problem is better than usual. a. b. c. 5. List any persons around whom you have greater difficulty talking and their relationship to you. a. b. c. 6. List any persons around whom you have the least difficulty talking and their relationship to you. a. b. c. 7. What is your typical reaction to your fluency problem?

Adult Fluency Case History Form Page 4 of 6 9. List prior treatment for your dysfluent speech. When Where How Long? Advice/Type of Therapy 10. How often do you stutter? 11. Do you have periods of time when you do not stutter? a. How long do they last? b. Are they related to who is listening? c. Are they related to what you are talking about? d. Are they related to your physical state at the time? e. Are they related to your emotional state? 12. Once a stuttering episode has started, do you try to stop it? If so, how? SOCIAL HISTORY 1. What is your occupation? Briefly explain your job responsibilities. 2. Who do you live with? Please include ages of children, if applicable. 3. Please list any hobbies or interests

Adult Fluency Case History Form Page 5 of 6 Additional Comments/Information: FINANCIAL RESPONSIBILITY I hereby agree to accept full responsibility for all fees for services rendered to the patient by the practitioner. I am also aware of the cancellation policy enclosed. Signed: Date: Driver s License Number: N J CANCELLATION POLICY Princeton Speech and Language Center is dedicated to providing quality services to our clients. We must stress that consistency of attendance is crucial in order for clients to effectively meet the goals of their treatment plan. In addition, therapy time is specifically reserved for your family and is unavailable for other clients. We are sensitive to the needs faced by the families of our clients however; it is necessary for us to enforce a cancellation policy. Except in cases of emergency or sudden illness, appointments not cancelled 48 hours in advance will result in a charge as though the appointment was held. We look forward to a positive relationship with you, as we strive to provide cutting edge, quality treatment and specialized programs. Thank you for your attention to this matter. Signed: Date:

Adult Fluency Case History Form Page 6 of 6 CLINICAL RELEASE OF INFORMATION Mr. Mrs. I, Ms., hereby give Princeton Speech-Language & Learning Center permission to discuss my case with the interdisciplinary professionals involved in my care, and to release any relevant clinical information to those professionals if requested. I also authorize PSLLC to release and/or share any information requested by my insurance company. (Client s Name) Name: Address: Phone: Name: Address: Phone: Signature of Patient: Date: Document must be signed by parent or guardian if patient is under 18 years of age.

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