GA Adult Intake Step 1 of 3 33% Patient's First Name:*Patient's Last Name:*Date of Birth:* MM slash DD slash YYYY Age:*Phone Number:*Email Address:* Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Occupation:Work Phone:Employer: Referred By:Phone:Address: Family Physician:Phone:Address: Single Married Domestic Partnership Divorced Widowed Spouse’s/Partner’s Name:Children (include name, gender, and age):Who lives in the home with you?What languages do you speak? If more than one, what is your dominant language?What was the highest grade, diploma, or degree you earned? Describe your speech-language problem:What do you think may have caused the problem?Has the problem changed since it was first noticed?Have you seen any other speech-language specialists? Who and when? What were their conclusions or suggestions?Have you seen other specialists (physicians, audiologists, psychologists, neurologists, etc.)? If yes, indicate the type of specialist, when you were seen, and the specialist’s conclusions or suggestions.Are there any other speech, language, learning or hearing problems in your family? If yes, please describe. Medical HistoryProvide the approximate ages at which you suffered the following illness or conditions.Adenoidectomy:Asthma:Chicken pox:Colds:Croup:Dizziness:Draining ear:Ear infections:Encephalitis:German measles:Headaches:Hearing loss:High fever:Influenza:Mastoiditis:Measles:Meningitis:Mumps:Noise exposure:Otosclerosis:Pneumonia:Seizures:Sinusitis:Tinnitus:Tonsillectomy:Tonsillitis:Other:Do you have any eating or swallowing difficulties? Yes No If yes, describe.List all medications you are taking.Are you having any negative reactions to these medications? Yes No If yes, describe.Describe any major surgeries, operations or hospitalizations (include dates).Describe any major accidents.Provide any additional information that might be helpful in the evaluation or remediation process. Insurance InformationPrimary Insurance:Policy Holder Name:Group Number:Phone Number: Secondary Insurance:Policy Holder Name:Group Number:Phone Number: Person completing the form:Relationship to the client:Date: MM slash DD slash YYYY