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INITIAL EVALUATION INTAKE FORM
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Feel free to call with any questions you might have or if you prefer to answer these questions over the phone.
(215)-645-2699 or
contact@fairmountspeech.com
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Email
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Your email
Today's date
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MM
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YYYY
PERSONAL INFORMATION
Client first and last name
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Your answer
Client or caregiver contact Information (phone number, email)
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Your answer
Address (street, city, state, zip)
Your answer
Date of birth
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MM
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DD
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YYYY
Emergency Contact Information (name, phone number)
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Your answer
Language(s) spoken
Your answer
Primary physician (name, phone number, address)
Your answer
Referring physician (name, phone number, address)
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Your answer
Other Physicians/Specialists involved in care
Your answer
CURRENT MEDICAL STATUS
Diagnosis (if known)
Your answer
Please describe your present issue
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Your answer
When did it start?
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Your answer
Has the problem stayed the same, improved or gotten worse? Please Describe.
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Your answer
Are your deficits related to work or an accident? If yes, please explain and include date of injury.
Your answer
Does anyone in your family have a history of the same (or different) difficulty?
Your answer
What do you think caused your current deficits?
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Your answer
Are you currently receiving assistance at home, work, school?
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Yes
No
Required
If yes, please describe the assistance needed.
Your answer
Briefly describe why you are seeking an evaluation by a speech-language pathologist at this time
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Your answer
What are you expecting out of the a speech therapy evaluation and treatment program?
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Your answer
Have you ever had a previous speech, cognitive, language or swallowing evaluation/treatment?
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Yes
No
Required
If yes, please describe when, by whom, and what the findings were if any.
Your answer
Are you currently working with another speech therapist?
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Yes
No
Required
Speech therapist name and contact information
Your answer
How do your current difficulties impact your life, social, work, hobbies, etc.?
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Your answer
What strategies do you use to help cope with this problem?
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Your answer
MEDICAL HISTORY
Please describe your current health status
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Your answer
Past medical history: Check all that apply
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Allergies
Asthma
Attention Deficit Disorder
Auto accident
Brain injury
Breathing problems
Cancer
Cardiac issues
Cleft palate
Cognitive issues
Degenerative illness
Dementia
Depression
Developmental delay
Diabetes
Ear infections
Encephalitis
G-tube
Hearing loss
Multiple Sclerosis
Parkinson's Disease
Pneumonia
Psychiatric issues
Respiratory problems
Seizures
Stroke/TIA
Swallowing problems
Trach
Other
Required
Please describe/include any information regarding your medical history (birth injuries, abnormalities, surgeries, chronic illnesses, accidents, diagnoses, etc.), when they were diagnosed and by whom
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Your answer
Have you ever had surgery or been hospitalized for a related issue?
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Yes
No
Required
If yes, please describe related surgeries or hospitalizations
Your answer
Are you currently on any medications? If so, please list medication name and reason for medication:
Your answer
Do you currently use any equipment? (communication device, walker, glasses, dentures, hearing aids, etc.) If yes, please list them.
Your answer
Have you ever been evaluated by the following specialties? Check all that apply
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Audiologist
ENT
Gaestroenterologist
Neurologist
Occupational Therapist
Otolaryngologist
Physical Therapist
Psychologist
Psychiatrist
None
Other:
Required
If yes, please describe the nature of the evaluation and any results:
Your answer
SOCIAL HISTORY
Occupation (employed, unemployed, retired?)
*
Your answer
Are you currently driving?
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Yes
No
Required
Education: What is the highest grade you completed?
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Your answer
Please list degree earned
Your answer
Did you have difficulty with any of the following prior to your current deficits?
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Learning
Understanding
Memory
Behavior
Attention
Reading
Speaking
Writing
Problem Solving
Eating, Drinking
Weight loss
Poor appetite
Hearing
Vision
None of the above
Other:
Required
If yes, please describe difficulty prior to current deficits.
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Your answer
What are your responsibilities in the home? Check all that apply:
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Caregiver
Cooking
Cleaning
Child care
Driving
Finances
Grocery shopping
Laundry
Repairs
Shopping
Yard work
Managing medications
Other:
Required
Please list your hobbies, daily routine/schedule, interests
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Your answer
Is there anything else that is important for us to know about you?
Your answer
How did you hear about Fairmount Speech and Swallowing Therapy?
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Facebook
Google search
Referral from physician
Other:
Person filling out the form (include relationship to client)
Your answer
What days and times work best for you and the client to attend weekly online therapy session? (Examples: evenings and weekends, Saturday and Sunday mornings, Wednesdays between 1 to 4pm)
Your answer
Do you have a computer/laptop webcam, ipad, tablet to use for online therapy sessions?
Yes
No
Clear selection
Do you have Google Drive (or Gmail)?
Yes
No
Clear selection
Thank you for taking the time to fill out this form
Please reach out for any additional questions/information (215)-645-2699 or
contact@fairmountspeech.com
I look forward to working with you!
A copy of your responses will be emailed to the address you provided.
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