ࡱ> IKH >bjbjVV ZB<<!PP+++$OOOOk\O%n...$$$$$$$&)$Q+! ".!!$E>%W$W$W$!Fl+$W$!$W$W$,W$OA" W$$T%0%W$l*M#l*W$l*+W$.  W$?...$$M$ ...%!!!!l*.........P Y:  Please check one: Hearing Eval _________ Diagnostic: ____________ Speech Therapy: ________ Rev: 06/15/10 California State University, Fresno Speech, Language and Hearing Clinic 5310 N. Campus Drive, PH 80 Fresno, CA 93740-8019 (559) 278-2422 w Fax (559) 278-5187 PLEASE ATTACH ANY REPORT FROM PREVIOUS AGENCY OR SCHOOL Adult Case History PLEASE PRINT IN INK OR TYPE ALL INFORMATION General Information Today s Date: Name: Date of Birth:____________ Gender___ Address: E-mail: City: Zip: Phone: (Home)_______________ (Cell) Occupation: Business Phone: Employer: Single: Widowed: Divorced: Spouses Name: Spouses Occupation: Names, ages, and gender of children: Referred By: Phone: Address: Have you been tested and/or evaluated at this clinic before? ___________ If yes, how long ago was your last visit? _________________________________________________________ Office Use Only: Date Received:___________________________________________________________________________ Dates Contacted:_________________________________________________________________________ Names and relation of other persons living in home: What languages do you speak? What is your primary language? Highest grade completed or degree earned? Describe your speech-language or hearing problem: What do you think caused the problem? When did you first notice the problem? How has the problem changed since you first noticed it? How has your communication problem affected your life? List other speech-language specialists or audiologists you have seen and describe their conclusions or recommendations: (Please provide copies of test reports/test results) List any other specialists (physicians, psychologists, neurologists, etc.) you have seen, and the specialists conclusions or suggestions: (Please provide copies of reports/ test results) Describe any other speech, language, learning, or hearing problems in your family: Medical History General health is: good fair poor Provide the approximate ages at which you experienced the following illness and conditions: Adenoidectomy Allergies Asthma Chicken pox Colds Convulsion Croup Diabetes Draining ear Ear Infections Dizziness Epilepsy Headaches Encephalitis German Measles Influenza Hearing Aids Heart problems Meningitis Hearing Loss High fever Numbness Mastoiditis Measles Otosclerosis Mumps Noise Exposure Sinusitis Paralysis Seizures Tonsillitis Pneumonia Tonsillectomy Ulcers Visual Problems Glasses Do you smoke? How much per day? List all prescription and nonprescription medication used during the past year: Describe any eating or swallowing difficulties you have experience: List any major accidents, illnesses, surgeries, or hospitalizations (include dates): Provide any additional information that you might believe to be helpful in the evaluation or remediation process: Person completing the form: Relationship to client: Signed: Date: PLEASE ATTACH ANY REPORT YOU HAVE FROM ANOTHER AGENCY, SCHOOL, OR DOCTOR. **Please Note: You must complete and sign the attached Observation Consent statement and return it with your case history form. Thank you for taking the time to fill out the forms completely and accurately. California State University, Fresno Speech, Language and Hearing Clinic 5310 N. Campus Drive PH 80 Fresno, CA 93740-8019 (559) 278-2422 w Fax (559) 278-5187 Observation Consent Consent is hereby given to faculty, students and other persons approved by the clinical supervisor at the Language, Speech and Hearing Clinic at California State University, Fresno to observe ___________________________________ in the clinic or in off campus settings. The purpose of these observations is to train University Communicative Sciences & Disorders students (both diagnostic and treatment sessions may be observed). Students from other departments studying children and adults with language, hearing, and speech disorders may also watch and listen if the supervisor gives permission. Parent/Guardian/Self (18 or older) Date California State University, Fresno Speech, Language and Hearing Clinic 5310 North Campus Drive M/S PH 80 Fresno, California 93740-8019 (559) 278-2422 (559) 278-5187 fax Consent and Release for Photographs or Videotape Consent is hereby given to the Language, Speech & Hearing Clinic, at California State University, Fresno, with approval of ________________________________ to take photographs, or videotape of _____________________________. These pictures will be used to train university students and demonstrate department activities to the general public. I understand that I will be able to view the photographs or videotape if I so request. _____________________________________ _______________________ Parent/Guardian/Self (18 or older) Date California State University, Fresno Speech, Language and Hearing Clinic 5310 N. Campus Dr PH 80 Fresno CA 93740-8019 (559) 278-2422 Fax (559) 278-5187 Release of Information to Language, Speech, and Hearing Clinic To:_____________________________ Date:____________________ ______________________________ ______________________________ ______________________________ Re:_____________________________ Birthdate:___________ _____________________________ _____________________________ _____________________________ You have permission from ___________________________ to provide the Language, Speech, and Hearing Clinic at California State University, Fresno, with copies of all records pertaini  '  , . 4 6   d f ÿte^RMG h:ZCJ h#5h:Zh#5CJaJ hG5CJhh#56>*CJaJhh=%56>*CJaJhhG56>*CJaJhG5CJaJh#CJOJQJh#CJOJQJhgkCJOJQJ h#CJ h#h(h:ZCJaJhCJaJh(h(CJaJh(h:Zh:ZCJaJh:ZCJaJhHCJaJ5f ( , .  d f  0*gd:Zdgd( ^`gd:Z ^`gdG$a$gdG$a$$a$gd:Z$a$gdHf $ JKLMk6h-.=AE&Jdez,0XZ\򼰩zjjh#CJUmHnHuh#CJOJQJh#CJOJQJh}iCJOJQJh9 h#>*CJ h#CJ h#5CJhGh#5CJaJhG5CJaJ h#5CJh:Zh#5CJ hNvCJ h:ZCJh:Zh:Z5CJ h(CJ h#CJh#h:Z) $ B M { " LM! 0*d&d P  T 0*d 0*d P0*d!#JLNvxz[jlnp 0* 0*dpY{1Ww'() \ l0*dh \ l 0*dh @ 0*d 0*d)z|~!#.gd9$a$d 0*d 0* 0*d&Je{,.0XZ;< $  dh $ dha$dh $a$gd9\sx="!!<>>>>>Ѽh&UhhAhV!CJaJUhV!5CJ\hV!hV!CJaJhHCJaJhH5CJaJhHhAhHCJaJhF}hH5CJaJhF}hH5CJ$aJ$ hHCJ h#CJ1Ostuvwx ^`gdA$a$gdH OP_`abcdefghi gdH $^a$gdA ^`gdA$a$gdA%=Swx F m r s !!gdV!$a$gdV!gdV!gdV!gdV! !!"!q!r!!!K<L<<<<<$=%=&=|=}====>>Y>>>>>>> gdV!ng to medical history and diagnostic services rendered or treatment given to ___________________________ from the dates of ____________ to ____________. Released information regarding the above named person is for the purpose of determining the most appropriate treatment for him/her. These records will be released only to authorized personnel in the clinic, including faculty members, clinic staff, licensed supervisors, and student clinicians. 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B S  ? 2@ t4BlXBXBTTXBYBd YB|ZBlYBL%YBYBXBYB|!YB(YBDXBXB[Bl[B[BT[BXB$[B[B|XB4[BXBD-B4BL8BD9B{ZBL[B,YBXBYBsZBDXB\[Bt[B|YB4YBDYBYB4YB$!YB\"YB*YBt-YBXB̹[B*B$[B%Y: E K W W  S^dpp3      !"#$%&'()*-+,./0123  ''D J U ] ]  ]cnvv3   !"#$%&'()*,-+./01239+*urn:schemas-microsoft-com:office:smarttagsState>**urn:schemas-microsoft-com:office:smarttags PostalCode81*urn:schemas-microsoft-com:office:smarttagsCity90*urn:schemas-microsoft-com:office:smarttagsplace;/*urn:schemas-microsoft-com:office:smarttagsaddress:.*urn:schemas-microsoft-com:office:smarttagsStreet=3*urn:schemas-microsoft-com:office:smarttags PlaceType=4*urn:schemas-microsoft-com:office:smarttags PlaceName )Y43310/.01+*43301/.01+*4331001+*0430143310/.01+*43310&* W`!0329CE8:T_7 > mo}8:5<!!3333333333333333333333q%'!'*6[n8 ^ z !,..//33D9V!=%V|'HRZU:Zd}igkG#(B}W(&U#AHNv!#@L88 2x@x x@xx4@xx@UnknownG* Times New Roman5Symbol3. * Arial9Palatino;WingdingsA BCambria Math"AhEKfEKfKa -a -!24d3HX(?G2!xx#California State University, FresnoThe Speech & Hearing ClinicHealth and Human ServicesOh+'0 8D d p | $California State University, FresnoThe Speech & Hearing Clinic Normal.dotmHealth and Human Services2Microsoft Office Word@F#@zP@Φ@Φa՜.+,0$ hp  California State University-  $California State University, Fresno Title  !#$%&'()*+,-./012345679:;<=>?ABCDEFGJRoot Entry FL1Table"l*WordDocumentZBSummaryInformation(8DocumentSummaryInformation8@CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q