Voice evaluation registration packet

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II. EDUCATION/SOCIAL HISTORY Highest level of schooling completed (please circle one): Grade School High School Trade School College Graduate Doctorate Other: ___________ Are you currently employed? ___YES ___NO Do your symptoms interfere with your ability to do your job? ___YES ___NO Current/Past Occupation: ___________________________________________________________________________________ Are you retired? ___YES ___NO If so, for how long? ________________________________________________________ If student, please list grade, school attending, and teacher/speech-language pathologist:___________________________________ _________________________________________________________________________________________________________ Name of school / daycare provider (in home/out of home):__________________________________________________________ Please list any sports/community activities or hobbies you enjoy: __________________________________________________ _________________________________________________________________________________________________________ III. MEDICAL HISTORY What symptoms/problems led you to request this <strong>evaluation</strong>? __________________________________________________________________________________________________________ Date of onset (month, day, year problem was first noticed): _________________________________________________________ Has this problem improved/deteriorated since the onset? Please Explain: __________________________________________________________________________________________________________ Have you been treated for this problem before? ___YES ___NO If yes, state where: _____________________________________ Approximately when: ________________________ Treatment given: ________________________________________________________________________________ Was the treatment successful? ___YES ___NO Have you had surgery/medical treatment for this problem before? ___YES ___NO If yes, please list the approximate date and type of surgery/medical treatment: ___________________________________________ List any other major medical illness or surgery that has occurred (may attach separate sheet, if needed)_______________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ Are you currently taking ANY medications? ___YES ___NO If YES, please complete the following regarding medications: (Please use back of form if necessary) MEDICATION REASON FOR TAKING SIDE EFFECTS MEDICATIONS EXPERIENCED ___________________________ ________________________ _______________________ ___________________________ ________________________ _______________________ ___________________________ ________________________ _______________________ ___________________________ ________________________ _______________________ ___________________________ ________________________ _______________________ 2
(MEDICAL HISTORY (continued) Please list any vitamins/supplements you may be taking, along with reason for taking: ___________________________________________________________________________________________________ ________________________________________________________________________________________________ If patient is a child, are there any significant birth or developmental problems to be noted? If so, please list.___________________ __________________________________________________________________________________________________________ Are you on an altered diet? (e.g. soft food, PEG-tube, thickened liquids) ___YES ___NO If YES, please describe: ______________________________________________________________________________________ Are you currently (or recently) under a specialty physician’s care? ___Y ___N If yes, why? ____________________________ ________________________________________________________________________________________________ Is there a family history of allergies? ___Y ___N If yes, please list. _____________________________________________ Please circle any of the following you have experienced: Facial Numbness Hoarseness High Fevers/Chills/Sweats Reflux/Heartburn Pneumonia Injury/Falls Fatigue Unexpected weigh gain/loss Nausea/Vomiting Head Trauma Weakness Night Pain Bowel Dysfunction Urinary Frequency Changes Stuttered Speech Orientation problems Difficulty with Judgment Maintaining Topic of Conversation Memory Focusing/Attending Vision Problems Reading Writing Slurred Speech Word Finding Problem Solving Expressing Thoughts Following Directions Coughing/Choking Throat Pain Swallowing/Chewing Radiation/Chemo Therapy If you have had treatment for any of the above symptoms, please describe: ____________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ Please circle all that apply: Aids/HIV Drug/Alcohol Abuse Psychiatric Treatment Allergies Emphysema Rheumatic Fever Anemia Fainting Rheumatic Heart Disease Asperger’s Fractures Seizures /Epilepsy Arthritis Glaucoma Shortness of Breath Asthma Heart Disease/Atrial Fibrillations Sinusitis Back Trouble Heart Attack Stomach Ulcers Bipolar Disorder Heart Murmur Stroke/TIA’s Bleeding Disease Hepatitis Swelling of Hands/Feet Bronchitis Herpes/Shingles Thyroid Disease Cancer High Blood Pressure Tuberculosis Chest Pain Jaundice Diabetes Congestive Heart Failure Kidney Disease Motor Vehicle Accident Congenital Heart Defect Learning Disabled Other ________________________ Convulsions Liver Disease Other ________________________ Depression Mental Retardation 3
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Voice evaluation registration packet

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