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The Fontbonne University Speech and Language Clinic

Kansas City, MO

Contact Information

Name
Birth Date
Address
(###) ### - ####
(###) ### - ####
Secondary contact address (if different from above)
(###) ### - ####
Who is completing this form?
If "other" please answer the questions as the client would answer.
Category of client:
Please choose the one that best applies.

Adult Case History

Did the problem begin gradually or suddenly?
Are there times when your speech is better than others?
Do others have a hard time understanding you?
Has the problem.
Have you had any changes to your vision related to your communication problem?
Are you able to read?
Are you able to write?
Do you use a computer?
Do you use any strategies or devices to help you communicate?
What is your highest education level?
Are you currently working?
Is your goal to return to work?
Are you currently driving?
Have you had any previous problems with your voice/speech/language/communication abilities
Have you ever received a speech/language evaluation?
Have you previously received or are you currently receiving any therapy (Speech, occupational, physical, other)?
Do you attend any type of support groups related to your communication disorder?
Do you participate in any community events (volunteer, church, community, associations, etc.)?

Medical History

Have you had any of the following conditions? Check all that apply.
Are you currently on any medication?
Please list your physician's name and address.
Have you had a history of hearing difficulties?
Do you have trouble with any of the following? Check all that apply.
Do you wear any of the following? Check all that apply.
Do you use a wheelchair?
Do you use a walker or cane?
Do you have difficulty using your hands?

Adult Case History

Diagnosis:
Have you previously received and/or are you currently receiving speech/language services?
Have you previously received and/or are you currently receiving any other therapy (occupational, physical, are, music, other)?

Medical History

Do you have any medical diagnoses (cancer, stroke, diabetes, etc.)??
Do you have any other syndromes?
Are you currently taking any medications?

Education History

Highest Education Level
Are you currently working?
Do you participate in any group or community activites?
Do you have hearing loss?
Do you wear any of the following? Check all that apply.
Do you have any vision problems?
Do you wear glasses?
Do you use a wheelchair?
Do you have trouble using your hands?
Do you use any strategies or devices to help you communicate?

History of Stuttering

Are there other individuals in your family background or immediate family who stutter
If you don't remember, you might ask parents or siblings.
Was the stuttering always the same or did it occur in different ways?
Where did the first blocks seem to be located?
When the stuttering first began, was there any avoidance of speaking because of it?
At the time when stuttering was first notices, what was your reaction? Check all that apply.

Development of Stuttering

Since the onset, have there been any changes in stuttering symptoms? Check all that apply.
Were there any periods (weeks/months) when the stuttering disappeared?
Were there any periods (weeks/months) when the stuttering increased?

Current Stuttering

I stutter when I (check all that apply):
Stuttering interferes with my (check all that apply):
Do you know any stutterers?
Do any members of your family have speech or language problems or learning disabilities?

Hearing

Do you have hearing loss in your right ear?
Do you have hearing loss in your left ear?
Is on ear better than the other
Which ear?
Was the hearing loss progressive?
Do you experience tinnitus?
In which ear?
Intensity of tinnitus?
Do you use a hearing aid?
In which ear(s)
Do you use a cochlear implant?
Which ear(s)?
Date implanted:
What is your highest education level?
Are you currently working?
Do you attend any type of support groups related to your communication disorder?
Do you participate in any community activities (volunteer, church, community associations, etc.)?
Do you have trouble with any of the following? Check all that apply.

Case History

What is your native country?
In what settings do you speak English? Check all that apply.
With whom do you speak English? Check all that apply.