Outpatient Rehabilitative Services

Harford Memorial Hospital
501 South Union Avenue
Havre de Grace, MD 21078
443-843-5331		 Physicians Pavilion II
Suite 514
510 Upper Chesapeake Drive
Bel Air, MD 21014
443-643-3257		 Sports Medicine & Rehabilitation Center
Y at Abingdon
101 Walter Ward Blvd.
Abingdon, MD 21009
443-409-0051
 
Outpatient Adult Communication Case History

Name:
Date of Birth: (Month/Day/Year) - -    Age:
Name of the person filling out this questionnaire:
Relationship

List the relation, name and age of other people in your household:
Relation Name Age

What languages do you speak?
If more than one, which is your primary language?

Please check the highest level of education that you have completed:

GED High School Diploma  Trade or Technical School Certificate
Community College  Degree  Bachelors Degree   Masters Degree Ph.D 
Other:
Employer: Retired? NO YES 
  If not, can you describe the type of work you do and what are your job responsibilities.
 

List your interest/hobbies and/or activities you engage in (e.g., clubs, organizations, etc.):

Daily Routines
Describe a typical day for you including household and daily responsibilities
Describe any assistance that you require with the following activities of daily living:
Skill
Yes
No
 Comments
Eating
Mobility
Toileting
Grooming
Dressing
Medication
Meal Preparation
Shopping
Housework
Laundry
Finances
Home Repair/Yard Work
Driving
Other:


Do you still drive?  If so, how often and approximate distances daily:
 
Daily Routines
Please describe the nature of your communication problem, including when you first noticed it and how it has changed since then:

(Maximum characters: 200)
 
What caused the problem:

(Maximum characters: 200)
 
How has the communication problem affected your social life and /or occupation:

(Maximum characters: 200)
 
Describe any specific communication situations that present difficulty to you:

(Maximum characters: 200)
 
Describe the reaction of people, including your immediate family to your communication problem:

(Maximum characters: 200)
 
Do you avoid any communication situations? NO YES If Yes, please explain:

(Maximum characters: 200)
 
What, if anything, have you tried to do to correct the communication problem?

(Maximum characters: 200)
Have you ever had a hearing evaluation?      NO YES
If Yes, when and by whom?

Please have these results faxed to our office (UCMC: 443-643-1802   HMH: 443-843- 8702)
 
Have you ever had an evaluation by a Speech-Language Pathologist?       NO YES
If Yes, when and by whom?

Please have these results faxed to our office (UCMC: 443-643-1802   HMH: 443-843- 8702)
 
Have you ever received Speech-Language Therapy?     NO YES
If Yes, when and by whom?

Please have these results faxed to our office (UCMC: 443-643-1802   HMH: 443-843- 8702)
 
If therapy was terminated describe why:
Please list any additional information that you think may be helpful in assisting us with your impairment(s):

Employment History

Please list your most recent information. Should you require additional space, please use the back side of this page.

Place Dates Position
Educational History

Please list your most recent information
School Location Degree Date

Medical History  
Describe your present health: Good Fair Poor

Physician(s)
Name Specialty Address Phone

List all medical diagnoses including dates

1. 6.
2. 7.
3. 8.
4. 9.
5. 10.


Check all that apply to your medical history:
Allergies Head injury Polio
Anemia Hearing problem Poor dentition/Dentures
Asthma Heart Trouble Psychological counseling
Broken Nose High Blood Pressure Scarlet fever
Bronchitis Hormone Therapy Seizures
Cancer/tumor(s) Incoordination of face or tongue muscles Sinus infection
Chicken Pox Influenza Smoking: How often:
Chronic colds/upper Respiratory infections Kidney problems Stroke
Chronic laryngitis Motor Disorder Syphilis
Cleft Palate Mouth breathing Tinnitus (ringing in the ears)
Diabetes Mumps Tremor/twitching
Diptheria Neurological Problem Ulcers
Dizziness Noise exposure Visual problems
Drinking: How Often: Numbness Whooping cough
Ear Disease Paralysis/paresis Other:
Emotional difficulty Parkinson’s disease  
Glandular imbalance Physical defect Other:
Glasses Pneumonia  

If you checked any of the above items, give the relevant details (e.g., how frequent are these episodes, how severe are these episodes, how many etc.)

(Maximum characters: 200)
 

List all periods of hospitalization for surgical or medical treatment including dates:

1.
2.
3.
4.
5.

List all health or medical problems experienced over the last 5 years:

1.
2.
3.
4.
5.

List all medication used over the past year (prescription, over the counter, herbal supplements/alternative medicines)

Please list the information regarding the most recent exams below:
Type of Exam Date Name of Professional Results
Physical Exam
Vision Test
Hearing Test
Psychological
Neurological
Other:

Social History  
Marital Status: Never Married Married Separated Divorced Widowed

Do you have children?   NO YES

If yes, please provide the information below:
Name Age Gender Name Age Gender
M F M F
M F M F
M F M F

Thank you for taking the time to complete this form in its entirety. The information that you have provided will assist us in delivering efficient and effective Speech-Language Services

Thank You!
Speech Pathology Dept of the Upper Chesapeake Health System
  Questions? Please call:
443-643-1801-Upper Chesapeake Medical Center
443-843-5331-Harford Memorial Hospital