REGISTRATION FORM

Please answer all questions as completely and accurately as possible.

o c ommuni c ue maintains confidentiality of all client records, including any documentation which you provide from other facilities.

If you have any questions, please feel free to contact us.

Thank you.

Registration Code:

contact@communicue.com

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contact@communicue.com

GENERAL INFORMATION

Name:*

Gender:*

Date of Birth:*

Country: *

State:

Street:

City:* Postal code:*

Phone:*

Mail (official): *

Mail (preferred for further communication):

Current Occupation:

Primary Funding Source:

Private

Insurance

Company

REFERRAL INFORMATION

Referred by:

Reason for Referral: *

Voice

Speech

Communication

Other:

Oops! It seems there is missing some important information. Please review the (*) required fields to ensure everything is complete.

MEDICAL HISTORY

PERSONAL HISTORY

Marital Status:

Number of children:

Their ages:

Pet(s):

Does anyone in your family have a developmental disability, syndrome,learning disability, or history of speech, language or hearing difficulties?

Yes (describe):

Native language:

Language(s) spoken at home:

Language(s) spoken in workplace/ community:

Hand dominance:

Right

Left

Ambidextrous

What are your interests and activities that you enjoy?

VOCAL HYGIENE

Daily water intake:

<2 glasses (500ml/16 oz)

3-4 glasses

5-7 glasses

8 or more glasses (>2l/ 2 oz)

Alcohol servings:

>3;

Caffeine intake (coffee, tea, cola, others):

>3;

Smoking history:

Nonsmoker

Former smoker:

Current smoker:

Other(tobacco, snus, vape):

Consumption:

MEDICAL HISTORY

General health:

Excellent

🤩

Good

🙂

Fair

😐

Poor

😰

Do you do any sports?

Yes (describe):

Do you have a hearing loss?

Yes

Do you wear a hearing aid?

Yes

Do you have any vision problems?

Yes

Do you wear eyeglasses or contact lenses?

Yes

Have you ever been seen by a Speech/Language Pathologist (SLP)?

Yes (describe):

Have you ever been seen by any of the following specialists? Check all that apply:

Neurologist

Psychiatrist

Physical Therapist

Dietitian

Ear Nose Throat Physician

Behavior Specialist

Orthodontist

Audiologist

Occupational Therapist

Psychologist

Are you under the care of a doctor or medical specialist now? If so, list name and reason:

Yes (describe):

Please check the boxes for all that apply to indicate whether you have/had any of the following:

Respiratory Problems (asthma, emphysema, other)

Allergies

Frequent Colds/ Sinusitis

Hearing Problems

Snoring

Frequent coughing

Laryngitis/ Hoarsness

Swallowing Difficulty

Dental Problems

Reflux (GERD)

Gastrointestinal (digestive)

Kidney Problems

Epilepsy/Seizures

Tremors

Headaches/ Migraine

Traumatic Brain Injury

Thyroid Problems

Diabetes

Heart Attack/ Disease

Stroke

Viruses (HIV, Herpes, Hepatitis)

Fatigue

Stress

Anxiety Disorder

Herniated disc

Asperger Syndrome

Mental Illness

Attention Deficit Disorder

Arthritis

Autoimmune Disease

Cancer

Other Neurological Disorders

If you checked any of the above, please explain and comment below:

Relevant medications and dosage:

If you have any reports from other professionals (evaluations, medical records, etc.), please provide copies of those documents along with this case history form.

(If you have more than one document, please upload it in a Zip file)

SELF-EVALUATION

VOCAL ACTIVITIES

What do you mainly use your voice for, how many hours per day?

How do you mainly use your voice?

One to one conversations

Talking to groups

In person

Online

Hybrid

With headset/ earphones

On speaker

Other:

Overall, I would rate my communication as:

Excellent

🤩

Good

🙂

Fair

😐

Poor

😰

COMMUNICATION HISTORY

Please check all statements and elaborate:

Not at all = 1; Severely =5

1 2 3 4 5

My communication interferes with my social activities.

My communication interferes with my performance at work.

My communication interferes with my home life.

I am not able to get somebody's attention.

I am concerned about how well people understand my speech.

My communication is not easily understood by people I know.

My communication is not easily understood by strangers.

At times, my speech improves, but it gets worse again.

I frequently say the wrong sounds in words.

My speech contains many word repetitions or prolonged sounds.

I often run out of breath while talking.

It takes a great amount of effort to talk.

Does your voice keep you from doing anything?

Describe:

How important it is for you to improve your voice and speech?

Describe:

How confident are you that you can improve your voice?

Describe:

Do you have any other comments that may be helpful to us in planning your evaluation?

Name 3 goals for your communication: *

Oops! It seems there is missing some important information. Please review the (*) required fields to ensure everything is complete.