Essence of Communication

Essence of Communication

Adult History

The information provided on this form is confidential. It is used to appropriately prepare for the evaluation.

At the time of the evaluation we may ask for clarification or discuss any further information

***Please fill out each line to the best of your knowledge or put N/A if not relevant***

Personal Information:

Client’s Name: ______DOB: ______Age: ______

Person completing form: ______Relationship: ______

Referral Information:

Describe what are your and/or other’s concerns are and why you are pursuing speech therapy services: ______

______

Medical Diagnosis for speech therapy: ______

Date of onset: ______

How does it impact your dailyfunctioning (home, work, community activities): ______

______

Referral Source(s):*** This information is required***

Primary Healthcare Provider: ______Phone #: ______

Practice Name: ______Specialty: ______

*** A copy of the evaluation will be sent to the primary healthcare provider, even if they did not make the initial referral ***

Referring Healthcare Provider:

___ Same as Primary

___ Other Healthcare provider (ex: ENT, Neurologist, etc)

Name: ______Phone #: ______

Practice Name: ______Specialty: ______

___ Not referred by a Healthcare provider (ex: friend, family member, etc)

Name: ______Phone #: ______

Association to client: ______

Previous Speech-Language Services: (hospital, clinic, center, etc):

Name of facility: ______Phone: ______

Provider’s Name: ______

Dates of service: ______

Status of these services: ___ Discontinued

___ Continue in addition to services at Essence of Communication

*** We will need copies of recent medical reports from referring physician and any previous speech therapy service providers prior to the evaluation***

If you are unable to provide the reports or have the provider fax us reports, we require a signed release of information and will request the records.

Demographic Information:

Employer: ______What type of work do you do? ______

Relationship status: ___Married ___Single ___Partner

Emergency Contact Person: ______Phone: ______

Relationship: ______

Other Physician Information: (Other physicians than listed above)

Name: ______Specialty: ______Phone: ______

Medical History

Describe your current general health and medical status: ______

______

Current Medications:

Name / Dosage / Diagnosis/Reason for taking

Lifestyle Habits (Previously and currently):

Habit / Amount / Frequency / Type / Current / Stopped?
Water How much do you drink a day? / N/A / N/A
Alcohol
Tobacco (cigarettes, chew, snuff)
Caffeine (coffee, tea)
Soda
Other:

General Medical Conditions (Please check all that apply, See next pages for more specific conditions):

___ Diabetes: ___Diet managed ___Medication managed ___Insulin pump

___ Overweight

___ Menopausal (pre, peri, post)

___ Hearing Impaired: ___Hearing aids (amplification) ___Cochlear Implant(s) ___Other: ______

___Vison impaired: ___Corrected (glasses, contacts, etc) ___Surgery (cataracts, laser correction, other) ___Blind

___Macular Degeneration ___Visual field deficits ___Other: ______

___Mobility issues: ___Uses cane/walker/ crutches ___Uses a wheelchair ___High risk for falls

Allergies(Please check all that apply and describe your reaction/response):

Allergen / Response / Reaction
Foods
Latex
Environmental
Medications
Other:

Medical History including major Illnesses / Injuries / Events (Please provide as much detail as possible):

***Please review the entire form below before you provide information***

Condition / Onset Date / Provide information regarding the indicated medical condition
Neurological
Stroke / CVA/ TIA
Progressive Disease: MS, ALS, Parkinson’s, etc
Seizures / Epilepsy
Encephalitis / Meningitis
Brain Injury: traumatic, concussion, etc
Brain Tumor/ Cancer: benign, malignant
Please indicate treatment provided
Brain / Head Surgery
Procedures: MRI, CT scans, biopsies, etc
Congenital disorder: Cerebral Palsy, etc
Other:
Ears, Nose, Throat, Face
Hearing Impaired: hearing aids, Cochlear implants, etc
Nose: polyps, sinuses, septum, etc
Vocal Cords/Folds:
Laryngoscopy
Trauma / Injury
Nodules/Polyps/ Cyst
Abuse
Surgery
Cancer: Laryngeal, Oral/Mouth, Tonsils,
Thyroid, Head &/or neck
Please indicate treatment provided
Surgery: Oral – other than regular dental work, Throat, Thyroid, Neck, C-Spine, face
Throat clearing / Coughing
not related to swallowing difficulties
Facial Trauma
Procedures: biopsies, injections, etc
Other:
Respiratory
Difficulty breathing at times / Shortness of breath at rest and/or exertion
COPD / Emphysema
Chronic cough of unknown cause
Asthma
Chronic Bronchitis
Use Oxygen/ CPAP. BiPAP
Frequent recurrent respiratory infections
Surgery including biopsies
Procedures: Bronchial washing, Pulmonary function test, etc
Cancer: Lung, etc
Please indicate treatment provided
Other:
Gastro – Intestinal / Abdomen
GERD / Reflux
Hiatal Hernia
Swallowing difficulties /Choking/ feeling food is stuck while eating
Coughing and/or throat clearing while eating
Unexplained weight loss or gain
Poor appetite
Change in taste and smell
Abdominal Surgery: gastric bypass, Hiatal hernia repair, bowel, other
Cancer: stomach, intestinal, liver, pancreatic
Please indicate treatment provided
Procedures: endoscopy, upper GI, dilatation, Modified Barium Swallow/ FEES, etc
Trauma
Other
Endocrine
Arthritis
Auto-immune disease
Hypothyroidism
Hyperthyroidism
Hormonal Imbalance
Cancer: Pituitary, Thyroid, Kidney, etc
Please indicate treatment provided
Other
Surgery
Procedures
Cardiac
Heart attack
Hypertension
Hypotension
Surgery: bypass, valve, pacemaker, defibrillator, stents, etc
Procedures: heart catherization, etc
Trauma
Other:
Cancer (other than those indicated in above areas)
Type / Onset date / Status and Treatment Provided: Chemo and/or Radiation
Surgery (other than those indicated in above areas where you required intubation/anesthesia)
Type / Date / Details - optional