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.

IDENTITY

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.

Client's first name: *

Client's last name: *

Client's date of birth: *

COMMUNICATION STATUS

Do you currently use any of the following: *

Interpreter (signed or spoken language)?Hearing or listening supports (e.g. hearing aids, visual supports, etc)?Speech or communication supports (e.g. speech generating device, PMV, etc)?Reading supports (e.g. reading assistance, screen reader, C-Pen, etc)?Writing supports (e.g. writing assistance, dictation software, etc)?None of the above

If yes to any of the above, please describe:

SWALLOWING STATUS

If yes to any of the above, please describe:

Are you currently on a modified food and/or liquid diet? Please describe:

Do you currently use any other food or mealtime supports (e.g. supportive seating, adjusted utensils, swallow strategies, caloric or nutrient supplements, etc)? Please describe:

FAMILY & SOCIAL HISTORY

What language(s) do you speak at home? *

Do you use any other language(s)?

Where do you live (e.g. own home, with family, renting, ACT Housing, supported accommodation, temporary accommodation, etc)?

Who do you live with? E.g. partner/children/parents/extended family/other? Please list:

Do any other close relatives (parents, grandparents, siblings, children, aunts, uncles, cousins) have, or have a history of difficulties with language, speech, reading, or spelling? Please describe:

Are your concerns affecting your family/home life?

Are your concerns affecting your ability to socialise or engage with others outside the home? E.g. with friends, clubs, interests, community?

EDUCATIONAL HISTORY

Highest education level completed:

Are you currently studying?

YesNo

Are your concerns affecting your educational performance?

WORK HISTORY

Are you currently working?

YesNo

Occupation:

Are your concerns affecting your job performance?

MEDICAL HISTORY

If yes to any of the above, please describe:

Are you currently taking any medication (including over-the-counter, e.g. for allergies)? If so, what medication and for what purpose? *

*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 yes to any of the above, how often and for how long?

Have you ever had any surgery to the head, neck, brain, face, mouth, ears, throat, or heart (including removal of tonsils/adenoids/wisdom teeth)? If yes, please list what procedure and when: *

Have you ever been under general anaesthesia or had oxygen or breathing support?

ADDITIONAL INFORMATION

Is there any other information you wish to provide about yourself, your history, your concerns, or which will help us provide the service?

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 info@northsidespeech.com.au

Upload:

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CONSENT

Who has legal authority to make decisions regarding your healthcare? *

Self (client)Other (e.g. appointed decision maker, guardianship arrangement, etc)

Name: *

Phone: *

Email: *

I confirm the information I have provided in this questionnaire is true and correct, to the best of my knowledge. *

Name of person completing this form: *

Relationship to client:

Signature: *

Clear

Date: *

Would you like your letter of summary and recommendations sent to another health professional or service?*

YesNo

Name:

*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.

If you wish to receive a copy of this completed form, please provide your email address:

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