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Adult Intake Form
Please complete and submit prior to scheduling an evaluation.
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Email Address
*
Your answer
Patient Name (Last, First)
*
Your answer
Is English your primary language?
Yes
No
Clear selection
Referring Physician (Name and Phone), if applicable
Your answer
Speech or language diagnosis, if known
Aphasia
Apraxia/Dyspraxia
Aphonia (without voice)
Dysarthria
Fluency (Stuttering/Cluttering)
Receptive-Expressive Language Disorder
Speech Sound Disorder (Articulation/Phonology)
Unknown
Other:
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Please describe your speech difficulty:
Your answer
When did the difficulty begin?
Your answer
Relevant medications/dosages:
Your answer
Was the onset gradual or sudden?
Gradual
Sudden
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Was anything done about your difficulty when it was first noticed? If so, please describe:
Your answer
Describe any changes that you have noticed in your speech since the difficulty began.
Your answer
Is the difficulty worse at certain times? If so, please explain.
Your answer
How would you rate the severity of the problem now?
Your answer
Other relevant medical history/diagnoses/surgery:
Your answer
Please check the characteristics of your speech NOW. This will aid in preparation for your evaluation.
Mispronounce or omit sounds when speaking
Foreign accent or regional dialect
Difficulty saying the 's' sound (lisp)
Difficulty recalling names of people, objects, etc.
Difficulty speaking in complete, well-organized sentences
Difficulty coordinating voice, tongue, lips, etc. to produce speech
Difficulty swallowing
Excessive drooling
Repeat sounds, words, parts of words, or phrases while talking (stuttering)
People complain that I talk too softly
People complain that I talk too loudly
Other:
Please describe further the items selected above.
Your answer
Have you had a speech-language evaluation in the past?
Yes
No
Clear selection
If yes, when and where?
Your answer
Have you received speech-language therapy in the past?
Yes
No
Clear selection
If yes, when, where, and for what reason?
Your answer
Have any other members of your family had speech and/or hearing difficulties?
Yes
No
Clear selection
Is there anything else about your history or current condition that is important to mention?
Your answer
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