ADULT INFORMATION PROFILE

The information you provide will help the Speech-Language Pathologist gain a thorough understanding of you and enable provision of the most appropriate service and management.

Identifying Information
First Name*
Last Name*
Date of Birth*
MM slash DD slash YYYY
Current Age*
Sex
- M
- F
Residential address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone - Home
Phone - Mobile*
Phone - Work
Phone - Fax
Email*
Occupation
Languages Spoken*
Speech, Language, Learning and Hearing
What are your main concerns?*
When were these difficulties first noticed?
Hearing
Memory
Voice quality
Stuttering
Pronunciation of sounds
Comprehension
Word finding challenges
Difficulties in formation of thoughts
Oral presentation
Conversation skills
Chewing/Eating/Swallowing
Medical History
Are there any current diagnoses (e.g., stroke, head injury, other neurological conditions)?
Any other pertinent injury, illness, surgery or medical conditions?
Current medications
Outpatient care
Are there other medical professionals involved? (Psychologist, Counselor, Speech-Language Pathologist, Occupational Therapist, Physiotherapist, Etc)
**IF you have a report from any of these specialists, please provide a copy.
Additional Comments/ Other relevant information
Is there any other information you would like to add?
Ongoing Availability
This assists us connecting you with a clinician who can match your schedule. Please list your availability using the following format: (e.g., Monday: 9:00 to 12:00, Tuesday: all day, Wednesday: 3:30 to 6:00, or n/a if this day doesn't work for your schedule.)
Monday*
Tuesday*
Wednesday*
Thursday*
Friday*
Saturday*
Sunday*
Additional Comments about Availability: (if you don't have a consistent schedule, and need to go week by week, please indicate so and some possible options for availability)
Service Delivery Preference*
- In-Person
- Teletherapy
- No preference
Name of extended health coverage and/or funding provider
Semiahmoo Speech Services Inc., has a 24 hour cancellation policy for all services. Once you have scheduled an appointment/s 24-hour cancellation notice is required, if notification is not received prior to 24 hours from the booked appointment, you will be billed for the session IN FULL. Please indicate you understand these conditions by printing your initials in the box*
Completed by
Date completed
MM slash DD slash YYYY
Location*
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ADULT INFORMATION PROFILE

Identifying Information

Speech, Language, Learning and Hearing

Medical History

Additional Comments/ Other relevant information