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District Speech - Adult Case History
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* Indicates required question
Email
*
Your email
Full Name (First, Last)
*
Your answer
Address
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Female
Male
Non-binary
Prefer not to say
Other:
Preferred Pronouns
She/her/hers
He/him/his
They/them/theirs
Other:
Clear selection
Referred by:
Your answer
Phone Number
*
Your answer
Occupation
*
Your answer
Marital Status
*
Married
Single
Separated
Divorced
Other:
Name of Partner
Your answer
How did you hear about District Speech?
*
Your answer
CONCERNS: Describe the speech and/or hearing problems/differences briefly. Is this the only problem?
*
Your answer
HISTORY OF SPEECH PROBLEM/MEDICAL DIAGNOSIS (include age of onset)
*
Your answer
What attempts have been made to treat this problem?
*
Your answer
When was treatment?
Your answer
Results of this treatment?
Your answer
Describe any circumstances that change the symptoms:
Your answer
Do you consider this problem/difference mild, moderate, or severe? (if other, please explain)
*
Mild
Moderate
Severe
Other:
Is this problem/difference interfering with your educational, social or vocational plans?
*
Yes
No
If so, explain (e.g. confidence)
Your answer
Do people have difficulty understanding you when you talk to them?
*
Yes
No
Maybe
If so, do you know why?
Your answer
Have you ever "lost your voice"?
*
Yes
No
If so, describe the circumstances and the duration:
Your answer
Was English your first language?
*
Yes
No
Other languages spoken:
Your answer
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