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Speech Therapy Consent
Occupational Therapy Consent
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Speech Therapy – Adult Questionnaire
Step
1
of
6
– Patient Information
16%
Client Name
(Required)
First
Last
Client Date of Birth
DD slash MM slash YYYY
Gender
Male
Female
Prefer not to answer
Phone
(Required)
Email
(Required)
Reason for Referral
Referred by
Home Address
Street Address
Address Line 2
City
Emergency Contact Number
(Required)
Primary Medical Diagnosis
(Required)
Date of Onset
(Required)
MM slash DD slash YYYY
Relevant Past Medical History
(Required)
Neurological, surgeries, trauma, chronic conditions):
Current Medications
Vision/Hearing Status
(Required)
Other Therapies Received
(Required)
Physiotherapy
Occupational Therapy
Psychology
Dietetics
Other
Select All
Other therapy
(Required)
Presenting Concerns
(Required)
Slurred Speech
Word finding difficulty
Understanding speech
Reading/writing difficulty
Voice changes
Memory/attention difficulties
Other
None of these
Select All
Check all that apply
Other concerns
(Required)
Onset of difficulties
(Required)
Sudden
Gradual
Impact on daily life:
(Required)
Current diet
(Required)
Normal
Soft
Pureed
Thickened liquids
Alternative feeds (Peg/NG tube)
Reported difficulties
(Required)
Coughing/choking on food/ liquids
Drooling
Difficulty chewing
Prolonged meal times
Weight loss/dehydration
Other
Other difficulties
(Required)
Previous swallow assessment/interventions
Languages spoken
(Required)
Education/Occupation
(Required)
Living situation
Alone
With family
Care facility
Facility
(Required)
Support system
Hobbies/interests
What would you like to improve with therapy?
(Required)
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