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The Fontbonne University Speech and Language Clinic
Kansas City, MO
Contact Information
Name
First Name
Last Name
Birth Date
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Month
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Year
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2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Address
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Preferred phone
(###) ### - ####
Secondary phone
(###) ### - ####
Email
Secondary contact person name
Relationship to client
Secondary contact address (if different from above)
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Secondary contact phone number
(###) ### - ####
Who is completing this form?
Client
Other
If "other" please answer the questions as the client would answer.
If you are completing this form for someone else, what is your relationship to the client?
Please list your phone number and email address, if different from the above.
Please list the name and relationship of other person(s) living in the home.
Referred by:
Category of client:
Acquired disorder
Developmental disabilities
Stuttering / cluttering
Rehabilitation / cochlear implant user
Accent modification / improving spoken English
Please choose the one that best applies.
Adult Case History
Describe your communication problem in as much detail as possible.
What do you think caused the problem?
Give approximate age when the problem was first noticed.
Did the problem begin gradually or suddenly?
Gradually
Suddenly
What made you aware of the problem?
Are there times when your speech is better than others?
Yes
No
Please describe.
Do others have a hard time understanding you?
Yes
No
Has the problem.
Remained the same
Improved
Worsened
Please provide additional comments to the previous question, if applicable.
Have you had any changes to your vision related to your communication problem?
Yes
No
Are you able to read?
Yes
No
Somewhat
Please describe your reading abilities and limitations.
Are you able to write?
Yes
No
Somewhat
Please describe your writing/typing abilities and limitations.
Do you use a computer?
Yes
No
Please explain your basic use of computers.
Do you use any strategies or devices to help you communicate?
Yes
No
Please describe.
What is your highest education level?
High school
College / university
Advanced degree
Other
Are you currently working?
Yes
No
Is your goal to return to work?
Yes
No
What type of work did/do you do?
Are you currently driving?
Yes
No
Have you had any previous problems with your voice/speech/language/communication abilities
Yes
No
Please describe.
Have you ever received a speech/language evaluation?
Yes
No
When and where did the evaluation take place?
What were the results and/or recommendations of the evaluation?
Have you previously received or are you currently receiving any therapy (Speech, occupational, physical, other)?
Yes
No
Please list the type, location and approximate dates of the therapy you have received.
Do you attend any type of support groups related to your communication disorder?
Yes
No
Please indicate what type of group, when it meets, etc.
Do you participate in any community events (volunteer, church, community, associations, etc.)?
Yes
No
Please describe.
Medical History
Have you had any of the following conditions? Check all that apply.
Heart problems
Throat cancer
Stroke
Hoarseness or loss of voice
Head injury
Hearing loss
Seizures
Other
None of the above
Please indicate when you experienced the condition(s).
Are you currently on any medication?
Yes
No
Please list the medications you're currently taking.
Please list your physician's name and address.
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Please share your physician's phone number.
Have you had a history of hearing difficulties?
Yes
No
Do you have trouble with any of the following? Check all that apply.
Hearing in a group
Talking to one person
In church
Listening to TV
Talking on the phone
None of the above
Do you wear any of the following? Check all that apply.
Hearing aid
Cochlear implant
Glasses
Dentures
Do you use a wheelchair?
Yes
No
Do you use a walker or cane?
Yes
No
Do you have difficulty using your hands?
Yes
No
Please describe.
Please include any additional information that you think may be helpful or that you would like us to know.
Adult Case History
Diagnosis:
Autism
Asperger Syndrome
Down Syndrome
Intellectual disability
Other:
Other Value
Please describe your communication problem in as much detail as possible.
Have you previously received and/or are you currently receiving speech/language services?
Yes
No
Please indicate where and when the services were received and the reason for discontinuing.
Have you previously received and/or are you currently receiving any other therapy (occupational, physical, are, music, other)?
Yes
No
Please indicate the type, location and approximate dates of previous and other therapies.
Medical History
Do you have any medical diagnoses (cancer, stroke, diabetes, etc.)??
Yes
No
Please list your diagnoses.
Do you have any other syndromes?
Yes
No
Please list your other syndromes.
Are you currently taking any medications?
Yes
No
Please list your medications.
Education History
Highest Education Level
High School (regular or special education)
Technical School
College
Other
Are you currently working?
Yes
No
Please indicate type of work and setting.
Do you participate in any group or community activites?
Yes
No
Please describe.
With whom do you communicate on a regular basis?
Do you have hearing loss?
Yes
No
Do you wear any of the following? Check all that apply.
Hearing aid
Cochlear implant
Do you have any vision problems?
Yes
No
Do you wear glasses?
Yes
No
Do you use a wheelchair?
Yes
No
Do you have trouble using your hands?
Yes
No
Please describe.
Do you use any strategies or devices to help you communicate?
Yes
No
Please describe.
What is your goal for speech/language therapy?
History of Stuttering
Are there other individuals in your family background or immediate family who stutter
Yes
No
Please describe.
Please list the approximate age at which your stuttering was first noticed?
Who first noticed your stuttering?
In what situation did this occur?
Describe any situations or conditions that you associate with the onset of stuttering.
What were the first signs of stuttering?
If you don't remember, you might ask parents or siblings.
Was the stuttering always the same or did it occur in different ways?
Always the same
Sometimes different
Please describe how the stuttering has been different.
Where did the first blocks seem to be located?
Tongue
Lips
Chest
Diaphragm
Throat
Approximately how long did each block (on one word) seem to last?
Was the stuttering easy or was there force at the time when the stuttering was first noticed?
Were the words that were stuttered at the beginning of sentences, or were they scattered throughout the sentence being said?
When the stuttering first began, was there any avoidance of speaking because of it?
Yes
No
Please describe.
At the time when stuttering was first notices, what was your reaction? Check all that apply.
Awareness that speech was different
Indifference to the difference
Surprise
Anger or frustration
Fear of stuttering again
Shame
Other:
Other Value
What attempts have been made to treat the stuttering problem?
Development of Stuttering
Since the onset, have there been any changes in stuttering symptoms? Check all that apply.
Increase in number of repetitions per word
Amount of force used increased
Amount of force used decreased
Increase in length of block
Periods of no stuttering
More precise in speech attempts
Lowered voice loudness
Slower rate of speech
Change in location of force when stuttering (if force is present)
Looking away from listener
Describe any that apply.
Were there any periods (weeks/months) when the stuttering disappeared?
Yes
No
Were there any periods (weeks/months) when the stuttering increased?
Yes
No
Please describe the "worse" periods, if applicable.
Current Stuttering
Please describe any situations that are particularly difficult.
Please list any situations that never cause difficulty.
I stutter when I (check all that apply):
Talk to young children
Say your name
Answer direct questions
Talk to adults, superiors at work, teachers
Use new words that are unfamiliar
Use the telephone
Read aloud
Recite memorized material
Ask questions
Talk to strangers
Speak when tired
Speak when excited
Talk to family members
Talk to friends
Stuttering interferes with my (check all that apply):
Career
Social relationships
Success in school
Success on the job
Daily life
Do you know any stutterers?
Yes
No
Describe your relationship to them.
Describe what your stuttering currently looks and sounds like.
Describe any learning or reading problems you experienced as a child or are currently experiencing.
Do any members of your family have speech or language problems or learning disabilities?
Yes
No
Please describe.
Please add anything else you would like to include and think might be important.
Hearing
Please provide the date, location and results of previous hearing screenings.
Do you have hearing loss in your right ear?
Yes
No
Do you have hearing loss in your left ear?
Yes
No
Is on ear better than the other
Yes
No
Which ear?
Right
Left
Age of onset:
Was the hearing loss progressive?
Yes
No
Please provide any other details.
Do you experience tinnitus?
Yes
No
In which ear?
Right
Left
Both
Intensity of tinnitus?
Intermittent
Constant
Please provide any other details.
Please list any other illnesses you may have.
Please list all medications you take.
Do you use a hearing aid?
Yes
No
In which ear(s)
Left
Right
Both
How long have you worn your hearing aid(s)?
Please describe the benefits/concerns related to your hearing aid.
Do you use a cochlear implant?
Yes
No
Which ear(s)?
Left
Right
Both
Date implanted:
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Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Please indicate if you had previous therapy after receiving your implant (where, when, length of time, etc.).
What is your highest education level?
High school
College/university
Advanced degree
Other
Are you currently working?
Yes
No
What type of work do you do?
Do you attend any type of support groups related to your communication disorder?
Yes
No
Please indicate what type of group and when it meets.
Do you participate in any community activities (volunteer, church, community associations, etc.)?
Yes
No
Please describe your community involvement.
Do you have trouble with any of the following? Check all that apply.
Hearing in a group
Talking to one person
In church
Listening to TV
Please comment on your main concerns regarding your hearing and what you would like therapy/rehabilitation to focus on.
Case History
What is your native language?
What is your native country?
Afghanistan
Aland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State of
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-bissau
Guyana
Haiti
Heard Island and Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People\'s Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People\'s Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Republic of Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova, Republic of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania, United Republic of
Thailand
Timor-leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
List any additional languages spoken.
Age English instruction began?
How long have you spoken English?
How often do you speak English currently?
In what settings do you speak English? Check all that apply.
School
Work
Free time
Other:
Other Value
With whom do you speak English? Check all that apply.
Teachers
Parents
Friends
Roommates
Peers/other students
Co-workers
Other:
Other Value
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