<p> Speech and Hearing Clinic (480) 965-2373 PO Box 870102 Fax: (480)965-0076 Tempe, AZ 85287-0102</p><p>Apps: ASU Peer Program for Socialization Case History and Registration</p><p>Today’s Date: ___/___/____ Month/Day/Year General Information </p><p>Client Name: ______Date of Birth: ___/___/______Male ___Female Last First Middle Month/Day/Year</p><p>Parent Name: ______/______Last (mother) First Last (father) First Address: ______Street/P.O. Box City State Zip</p><p>Telephone: ______Home Work Cell</p><p>Email address: ______</p><p>List people in your household. Name Relationship Age</p><p>What languages do you speak? ______</p><p>If more than one, which is your primary language? ______</p><p>List hobbies and social activities.</p><p>Name of person filling out this questionnaire: ______Relationship to client: ______</p><p>Statement of the Problem</p><p>Describe the nature of the communication or socialization problems. When was the problem first noticed and by whom?</p><p>How has the problem changed since then?</p><p>What have you done to treat the problem?</p><p>How has the problem affected your life?</p><p>Describe any specific communication situations that present difficulty for you.</p><p>Please list any additional information that you think may be helpful in assisting with your problem.</p><p>Previous Related Testing</p><p>Please list the information regarding the most recent exams below: Types of exam Date Names of Professionals Results & Recommendations Speech and Language</p><p>Hearing Test</p><p>Psychological or Neuropsychological Examination Other:</p><p>Describe any previous speech language therapy, if received. Name of Professional Duration Goal(s) Results Reason for Termination</p><p>Educational History</p><p>Please list your most recent information. Name of School Dates Attended Outcome</p><p>Medical History </p><p>Describe your present health: ____ Good ____ Fair ____ Poor</p><p>Describe any major illnesses, accidents, injuries, operations, and hospitalizations (include age) experienced. Incident Date or Age</p><p>List all medical diagnoses, including date of diagnosis and professional making diagnosis. Diagnosis Date Name of Professional</p><p>Describe any medical treatment you are currently receiving.</p><p>Provide names and dosage of any medications that you are currently taking. Medication Name Dose Strength Date Started Please list the information regarding the most recent medical exams below: Type of exam Date Names of Professionals Results Physical exam Vision Test Other:</p><p>Do you wear: ____ Hearing Aid ____ Glasses </p>