Patient Case History – Cognition & Aphasia

Patient Case History – Cognition & Aphasia
Patient Name:________________________________________________________ Date:___________
Person Completing Form:_____________________________Relationship to Patient_________________
Your Phone Number:_______________________Client Birthplace & Birthdate:_____________________
Reason for Most Current Hospitalization:____________________________________________________
1. What do you feel is the patient’s problem?:_______________________________________________
_____________________________________________________________________________________
2. What was the date of injury or of the onset of the illness (head injury, stroke, illness, etc.)?: _______
_____________________________________________________________________________________
3. What was the patient’s handedness (before stroke or disease onset)?:____Right ____Left _____Both
4. Does the patient wear glasses?:_________________________________________________________
5. Does the patient see well enough to read?:_______________________________________________
6. Does the patient have any other visual problems, such as right or left visual field cut or cataracts?:
_____________________________________________________________________________________
7. Does the patient have a hearing loss?________________Does the patient wear a hearing aid?______
8. How would you describe the patient’s general health?
_____________________________________________________________________________________
_____________________________________________________________________________________
9. Please list the patient’s current medications and dosages (if known):___________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
10. List the members of the immediate family:
Name Age Relationship Phone Number Living with Patient?
_________________ ____ ______________ ____________ _______________
_________________ ____ ______________ ____________ _______________
_________________ ____ ______________ ____________ _______________
_________________ ____ ______________ ____________ ______________

11. Does the patient have a history of the following?
Onset Date and Current Status
Stroke Yes No
Aphasia Yes No
Other Communication Disorder Yes No
Right-or-Left-Sided Weakness Yes No
Dementia Yes No
Memory Impairment Yes No
Other Neurological Disease Yes No
Head Injury Yes No
Seizure Disorder Yes No
Clinical Depression Yes No
Psychiatric Problems Yes No
Alcohol Abuse/ Problems Yes No
Other Substance Abuse Yes No
Other Major Illness Yes No
12. If the patient is not living at home, where does he/she live?:_________________________________
13. What is the patient’s native language?: __________________________________________________
If not English, at what age did the patient learn English?:_______________________________________
14. What is the patients highest level of education?:__________________________________________
15. What (is/was) the patient’s primary occupation?:_________________________________________
16. Patient’s mother’s name:_______________________Living____________Deceased____________
Patient’s father’s name:_________________________Living____________Deceased____________
17. Marital Status: Single___Divorced___Widowed___Separated___Married___Remarried___

18. Does the patient have children or grandchildren? If so, please complete the information below:
Children Age Address (city & state)
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
Grandchildren Age Address (city & state)
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
________________ __________________ _____ _____________________________________
19. Does the patient need to be taken care of at all times?:_______ _____________________________
_____________________________________________________________________________________
20. To what extent can the patient care for him/herself (dress, feed, and wash himself)?:_____________
______________________________________________________________________________________
21. Describe the patient’s ability to communicate:_____________________________________________
______________________________________________________________________________________
22. How much does he or she talk or write now (hourly, daily, frequently, occasionally, etc.)?:__________
______________________________________________________________________________________
23. To what degree do other adults understand the patient’s communication?:_____________________
______________________________________________________________________________________
24. What strategies, if any, have you found useful to help with the patient’s communication?:_________
_____________________________________________________________________________________
25. Describe patient’s skills and living situation prior to this illness (e.g. was he/she functioning independently,
living alone, communicating with others, etc.). How has he/she changed?:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________

26.
Is he or she attempting to communicate verbally? Yes No
Is he or she attempting to communicate in writing? Yes No
Is he or she attempting to communicate using gestures? Yes No
Is his or her speech intelligible? Yes No
Is his or her writing intelligible? Yes No
Is there automatic speech (e.g., “Hello”, “Thank You”, “I’m fine”) Yes No
Have you read or heard anything about aphasia or dementia? Yes No
27. Below are words that describe a person’s personality and behavior. Circle those words that you feel
apply to the patient’s previous status (before illness/accident).
Happy Fights often Sad Enthusiastic Patient
Very friendly Warm Independent Energetic Intense
Moody Critical Dependent Prefers to be alone Jealous
Authoritarian Supportive Impatient Shy Receptive
Bossy At ease Responsive Cooperative Relaxed
Active Indifferent Distractible Outgoing Directive
Tense Listless Cold Can’t sleep Affectionate
Even tempered Quarrelsome Vigorous Easily fatigued Curious
28. Does the patient watch TV? If so, what are his or her favorite programs?:______________________
_____________________________________________________________________________________
29. Does the patient read much? If so, what type of reading material does he or she enjoy?:__________
_____________________________________________________________________________________
Thank you so much for taking the time to complete this referral packet