Medical History
Name (*)

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Date of birth (*)

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Address (*)

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Phone

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Email(optional)

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Occupation

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Family physician

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Referring physician

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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? (*)

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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 Symptom/Problem

Difficulty swallowing (*)

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Difficulty expressing thoughts (*)

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Difficulty being understood by others (*)

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Difficulty 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?

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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Occupation

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Do you currently work?

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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.

Date

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Patient Name

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by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.