Case History Form (Adults)

This form is for clients who are adults

If you are an adult and the appointment is for yourself, you do need to complete this form.

If you are the parent or caregiver of child (0-17 years) and the appointment is for your child, you do not need to complete this form. 

If you are the guardian or de-facto guardian for someone (18 years or older) who has a disability and the appointment is for that person, you do need to complete this form.

The purposes of the Case History Form are to: 

  • collect the information required to accurately assess your communication and/or swallowing status, and

  • collect the information required to contribute to an ethical and evidence-based Treatment Plan.

The information you provide is considered ‘health information’ under law. The information you provide is confidential and is stored securely, consistent with our Privacy Policy

Please fill out this questionnaire as fully as you can. We appreciate that you have seen multiple specialists in the past who ask similar questions, and it can be repetitive to continue to provide this information. Case history is an important part of your health record, and informs both our diagnosis and Treatment Plan.

The more information you are able to provide us before your appointment, the more we will be able to tailor your appointment to your concerns.


We appreciate that you have already provided us with a name and date of birth. We are requesting this information again as it allows our computer system to automatically match it up to the correct file, so that we can find your information easily in the future.







*Current or previous use of any of these substances can affect communication and swallowing status. It is important you answer honestly to enable us to provide an accurate diagnosis. Your responses are protected health information.


If you have any letters, reports, test results, or similar, that are relevant to your concern, please upload here.

Examples may include letter(s) from a specialist, report(s) from another health professional, hearing assessment, videostroboscopy (x-ray) or nasoendoscopy results.

Any documents uploaded form part of your health record, and are transmitted and stored securely in line with our Privacy Policy.

Alternatively, documents can be emailed to




*If you have been referred by your GP, or are receiving a Medicare-rebate for your appointment, we are required to send a copy to your GP.