University of Oregon HEDCO Clinic Fluency Center Phone 541-346-0923 Fax 541-346-6772 Physical Address: Mailing Address: HEDCO Education Complex HEDCO Clinic 1655 Alder Street, Eugene, OR 97403 5207 University of Oregon, Eugene, OR 97403 Diagnostic Intake Form for Adults Who Stutter Please fill-out this form to the best of your knowledge. If any section feels uncomfortable and you prefer to skip the section and discuss in-person, then please feel free to skip those items. We will review these items together during the introductory diagnostic sessions (first and second session). Thank you. Feel free to email, call, or text Dr. Jessica L. Fanning with questions: JFanning@uoregon.edu; w 541.346.2539; c 541.337.7086 Part I: PERSONAL INFORMATION Name: Check one: Male Female Date of Birth: Age: Home Address: Languages you speak: Languages you read: Best way to contact you (circle one): email / home phone / cell phone / other (please specify) Email address: Home Phone: Cell Phone: Other Family Contacts (phone, email): Occupation: Current Work Location: Emergency Contact(s): University of Oregon Fluency Center Adult Intake Page 1 of 8
Part II: HISTORY OF SPEECH/LANGUAGE PROBLEMS 1. Please describe your speaking challenges in your own words (use any format: bullets, text): 2. How long have you had this speaking difficulty? 3. Please describe your history of stuttering: when stuttering started and how has it changed over the years. 4. Have you previously been assessed for speech/language concerns (circle one)? Yes / No If so, please describe (when, why, results if possible): University of Oregon Fluency Center Adult Intake Page 2 of 8
5. Have you previously received any speech/language intervention/therapy (circle one)? Yes / No If so, please use the table below to provide important or relevant details: Date range (start stop)? Where? With Whom? What type of therapy & What were results? Date range (start stop)? Where? With Whom? What type of therapy, What were results, What did you like/dislike? Date range (start stop)? Where? With Whom? What type of therapy, What were results, What did you like/dislike 6. Have any other family members had speech/language problems (circle one)? Yes / No If so, please indicate the person s relationship to you and the nature of the problem. University of Oregon Fluency Center Adult Intake Page 3 of 8
Please fill-in any information you know regarding your family and the related health issues: Name Date of Birth Present Location Education Type of Employment Your Father Your Mother Sibling? Sibling? Sibling? Father s side of the family Name Age Location Occupation Health Issues (If deceased, list age at death and cause) Mother s side of the family Name Age Location Occupation Health Issues (If deceased, list age at death and cause) University of Oregon Fluency Center Adult Intake Page 4 of 8
7. How does stuttering affect your: a. Ability to participate in work activities? b. Ability to participate in social activities? c. Ability to interact with family members? d. Ability to interact with friends? e. Willingness to talk and communicate? f. Self-esteem or attitude toward self? 8. In what situations do you experience the greatest difficulty? 9. In what situations do you experience the least difficulty? 10. What factors seem to affect your fluency the most? 11. What else do you think we should know about you or your stuttering? 12. Do you experience other health related issues? If so, please describe: University of Oregon Fluency Center Adult Intake Page 5 of 8
13. Do you take any medications? If so, please list name & quantity: 14. Do you have any tactile or sensory sensitivities or any motor issues that you know of and accommodate for yourself? If so, please describe (see examples below: 15. Check those that apply to you. These items do not indicate that anything is right or wrong they simply help to describe your sensory processing profile: bothered by clothes, certain materials, tags, seams, pantyhose, ties, belts, turtlenecks, etc. frequently tips chair on back two legs restless when sitting through a lecture, presentation, or movie constantly chews on ends of pens and pencils smokes cigarettes difficulty eating foods with mixed textures, or one particular texture constantly biting nails or fingers bites lips or inside of cheeks frequently shake your leg while sitting or falling asleep love to sleep with multiple or heavy blankets on top of you cracks knuckles often frequently have gum or hard candy in your mouth can't identify objects by feel if your eyes are closed disoriented and/or lost easily in stores, buildings, hiking, etc. can't sleep if room isn't completely dark fearful of heights difficulty concentrating on or watching a movie/tv show when there is background noise or distractions difficulty remembering or understanding what is said to you difficulty following directions if 2-3 directions are given at one time unable to complete concentration tasks if noises are present sensitive to sirens, dogs barking, vacuum cleaners, blenders, or other sudden/loud sounds you have difficulty learning new physical coordination tasks (sports, moving equipment) you describe yourself as clumsy, uncoordinated, and accident prone difficulty walking on uneven surfaces difficulty with fine motor tasks such as buttoning, zipping, tying, knitting, sewing, closing ziploc bags frequently bump into people and things easily fatigued with physical tasks difficulty with authority figures trouble relating to and socializing with peers and colleagues strong feelings of anger or rage easily frustrated difficulty falling asleep or getting on a sleep schedule heart rate speeds up, and won't slow down when at rest, or won't speed up for tasks that require a higher heart rate difficulty with temperature regulation of body University of Oregon Fluency Center Adult Intake Page 6 of 8
Below, you will find a list of questions. Please read carefully and then answer with your first impression. Please check X the box that best answers each question. Question I like to meet new people Speech therapists are on my side I know when and how I stutter I am embarrassed by my stuttering I am able to communicate with my family I meditate People tell me that I stutter I feel anxious I don t think clearly when I stutter I sometimes laugh at myself I order what I want in restaurants I help friends when called upon I feel comfortable with others that stutter I cope well with stress I make a list of questions for my speech therapist I can talk with friends and family about my stutter I am a spiritual person I have a regular exercise routine Almost Never Occasionally Sometimes Frequently Almost Always I eat the right foods I view my stuttering as a chronic condition The important people in my life know I stutter I have a good support system I think people focus on my stuttering rather than hearing what I say I have a positive attitude I speak up when I have a question I have people who care about me I feel frozen in new speaking situations I express my feelings University of Oregon Fluency Center Adult Intake Page 7 of 8
Please read the following questions, and circle true or false I usually feel that I am making a favorable impression when I talk. I find it easy to talk with almost anyone. I find it very easy to look at my audience while speaking to a group. A person who is my teacher or my boss is hard to talk to. Even the idea of giving a talk in public makes me afraid. Some words are harder than others for me to say. I forget all about myself shortly after I begin to give a speech. I am a good mixer. People sometimes seem uncomfortable when I am talking to them. I dislike introducing one person to another. I often ask questions in group discussions. I find it easy to keep control of my voice when speaking. I do not mind speaking before a group. I do not talk well enough to do the kind of work I d really like to do. My speaking voice is rather pleasant and easy to listen to. I am sometimes embarrassed by the way I talk. I face most speaking situations with complete confidence. There are few people I can talk with easily. I talk better than I write. I often feel nervous while talking. I find it hard to make talk when I meet new people. I feel pretty confident about my speaking ability. I wish that I could say things as clearly as others do. Even though I know the right answer I have often failed to give it because I was afraid to speak out. University of Oregon Fluency Center Adult Intake Page 8 of 8