ADULT NEUROPATHOLOGY CASE HISTORY FORM
GENERAL INFORMATION
Date:_________
Name: ________________________Birth Date: _________Sex: ____ Age: ____
Address: _________________________________ Phone: __________________
Street
City
ST/Zip
Email:___________________________________________________________
Person filling out this form: __________________________________________
(Name and Relationship to Client)
Person(s) or agency who referred you to this clinic: _______________________
PERSONAL AND FAMILY HISTORY
Marital Status:
Single _____ Married _____ Separated _____
Divorced _____ Widowed _____ Remarried _____
Spouse’s Address: _________________________________ Phone: __________
Children:
Name
Address
Age
_____________________________________________________
_____________________________________________________
_____________________________________________________
Grandchildren: Number: _____ Ages: __________________________________
Father’s Name: ___________________________ Living? _____ Deceased? ____
If deceased, give cause of death __________________________________
MEDICAL INFORMATION
Date of injury? ____________________
Cause of injury? ____________________________________________________
Was the client unconscious? _____ If yes, for how long? ____________________
Was the client paralyzed? _______ Describe. _____________________________
Did the client have convulsions? _____ Have they been controlled? ___________
Does the client complain of dizziness, fainting spells, headaches? ___________________
Explain. ________________________________________________________________
Does the client have any visual or hearing problems? _____________________________
________________________________________________________________________
Has the client been treated for other illnesses?
Heart Condition _____
Stroke _____
Others ____________________________________________________________
Name and address of physician: _____________________________________________
_______________________________________________________________________
Has the client been seen for any of the following services:
Date
Person/Agency
Address
Speech
Therapy _______________________________________________________________________________
Psychological
Counseling/Testing ______________________________________________________________________
Vocational
Counseling ____________________________________________________________________________
Physical
Therapy _______________________________________________________________________________
Occupational
Therapy _______________________________________________________________________________
SPEECH AND LANGUAGE INFORMATION
Describe what the client’s speech was like at the onset of the problem: ______________________
_______________________________________________________________________________
_______________________________________________________________________________
How has it changed? _____________________________________________________________
_______________________________________________________________________________
CHECK THE APPROPRIATE COLUMN AS IT APPLIES TO THE CLIENT NOW. ADD COMMENTS
ON THE RIGHT IF NEEDED TO QUALIFY ANSWERS.
CAN
_____
_____
_____
_____
CANNOT
________
________
________
________
Indicate meaning by gesture.
Repeat words spoken by others.
Use one or a few words over and over.
Use emotional speech (swear words); count
or use other words that occur in a series,
days of week, prayers.
_____
________ Use some words spontaneously.
_____
________ Say short phrases.
_____
________ Follow requests and understand directions.
_____
________ Follow radio and television speech.
_____
________ Read signs with understanding.
_____
________ Read single words.
_____
________ Read newspapers, magazines.
_____
________ Tell time.
_____
________ Copy numbers, letters.
_____
________ Write name without assistance.
_____
________ Write single words.
_____
________ Write sentences, letters.
_____
________ Do simple arithmetic.
_____
________ Personal care (dressing, shaving, etc.)
_____
________ Handle money.
How did the client react when he/she discovered speech was difficult? _____________________________
______________________________________________________________________________________
What was your reaction?__________________________________________________________________
What do you do when the client cannot answer or when he/she tries to talk?_________________________
______________________________________________________________________________________
How does the client react when he/she cannot say what he/she wants to? ____________________________
______________________________________________________________________________________
PERSONAL AND SOCIAL INFORMATION:
1.
Before the injury:
Where did the client spend his/her childhood?_____________________________
_______________________________________________________________________________
Where did he/she go to school? ________________________________________
What is his/her highest grade/degree completed? __________________________
What is his/her occupation? ___________________________________________
Did he/she like his/her work? _________________________________________
How long has he/she worked at this job?_________________________________
What other work has he/she done? (give dates and length of time)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
What is the client’s native language? ____________________________________
Does he/she speak any other? _________________________________________
What hobbies or special interests does he/she have?________________________
_________________________________________________________________
_________________________________________________________________
What television programs does he/she enjoy? _____________________________
__________________________________________________________________
Did he/she do much writing (if so, what kind)?____________________________
__________________________________________________________________
Which hand did he/she prefer? ________________________________________
Describe the client’s personality:
1.
Before the injury:
Nervousness
________________________________________________________________________
Shyness
________________________________________________________________________
Moods
________________________________________________________________________
Getting along with others
________________________________________________________________________
2.
After the injury:
How has the client reacted to the injury? _________________________________
_________________________________________________________________
__________________________________________________________________
What seems to bother him/her the most? _________________________________
__________________________________________________________________
__________________________________________________________________
What personality changes have you noted? _______________________________
__________________________________________________________________
__________________________________________________________________
What is his/her attitude toward speech therapy? ___________________________
__________________________________________________________________
Has the physician talked to you about the client’s speech difficulty? ___________
__________________________________________________________________
Any further information which may aid the examination? ___________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
M: FormsVII: Adult Neuropathology Case History Form 9/10