Medical History
Client's Name (*)
Please let us know your name.
Date of birth (*)
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Physician
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Referring physician
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Today Date (*)
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if other describe relationship
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Person filling out this form (circle one)
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What is your primary language? What other language do you speak? (*)
Please write a subject for your message.
Medical history: please check all that apply. Please provide the dates where applicable
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What is your current state of health?


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Have you been hospitalized within the last 5 years? If so, why? Where?
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Please list any medications you are taking at this time
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SPEECH-LANGUAGE HISTORY
Have you ever had difficulty with:
swallowing
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Age
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expressing thoughts
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Age
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being understood by others
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Age
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understanding what others are saying to you
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Orientation/memory
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Problem solving
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Focusing/attention
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Reading/writing
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Finding words
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Maintaining topic of conversation
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Fluent speech (stuttering)
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Following directions
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Oral motor weakness (weakness, difficulty coordinating tongue, cheeks, lips, etc.)
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Voice difficulties
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Are there any other difficulties besides what is listed above?
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When was this problem first noticed?
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Did the problem begin suddenly or develop over time?
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Have you been seen by any other rehabilitation professionals?
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where & when
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Does this speech-language difficulty impact your ability to function in daily life?
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How or where does the speech-language difficulty impact you the most?
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Describe your daily communication needs:
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What do you hope to get out of speech-language therapy?
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SOCIAL AND EDUCATIONAL HISTORY
Marital Status
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Spouse or partner’s name:
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Children
Name & Age
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Do you currently work?
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Occupation
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Employer
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Highest level of education (grade or degree) completed
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Please provide other information you believe to be helpful in the development of your therapy here with us at Rock Therapeutic Services. Thank you.
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Captcha (*) Captcha
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