READING CLINIC QUESTIONNAIRE-ADULT
CASE HISTORY FORM
435 Dauer Hall
(904) 392-2041
GENERAL
BACKGROUND INFORMATION
Date: __________________
Client’s Name: ___________________________________
Birth date: ______________
Male [ ] Female [ ]
Parent’s name(s):
_________________________________________________________
Home phone no.:
_________________________ Work phone no.: __________________
Address:
________________________________________________________________
________________________________________________________________________
Please describe the problem
that brings you here: _________________________________
_________________________________________________________________________
_________________________________________________________________________
Who
referred you to this clinic? ________________________________________________
Has there been a diagnosis of
a reading, language or learning problem? Yes [ ] NO [ ]
If yes what type of problem
and when diagnosed: __________________________________
Has treatment been received?
Yes [ ] No[ ]
If yes, what type?
___________________________________________________________
Which
of the following professional services have been received: (check those that apply)
[ ] Physical therapy where ____________ when ____________ why_____________
[ ] Occupational therapy where ____________ when ____________ why _____________
[ ] Speech/Language therapy where ____________ when ____________ why
_____________
[ ] Behavioral therapy where ____________ when ____________ why
_____________
Psychological counseling where ____________ when ____________ why _____________
Have academic tutoring
services been sought? Yes [ ] No [ ]
If yes, in what area(s):
________________________________________________________
where ______________________ when
___________________________________
When were you first concerned
about a reading, language or learning problem? _____________
_____________________________________________________________________________
What reasons do you feel may
help explain these readings or other academic difficulties? ______________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________
MEDICAL
HISTORY
General
health conditions: Excellent [ ] Average [ ] Poor [ ]
Any serious illness? Yes [ ] No [ ] If yes, explain
______________________________________
Any operations? Yes [ ] No [ ] If yes, explain _________________________________________
Any
injuries? Yes [ ] No [ ] If yes,
explain ___________________________________________
Is there a history of:
High fever? Yes [ ] No [ ] If yes, when ______________________________________________
Headaches? Yes [ ] No [ ] If yes, when
______________________________________________
Seizures or
convulsions? Yes [ ] No [ ] If yes
when ____________________________________
Dizziness, fainting spells?
Yes [ ] No [ ] If yes when __________________________________
Eye
problems? Yes [ ] No [ ] If yes , when ___________________________________________
Memory
problems? Yes [ ] No [ ] If yes,
when ________________________________________
Has your hearing been
examined? Yes
[ ] No [ ]
If yes, is your hearing
normal? Yes
[ ] No [ ]
If no, explain
_________________________________________________________________
Did
you have 3 or more ear infections during the first year of life? Yes [ ] No [ ]
Did you have an ear infection
that lasted 3 months of more? Yes
[ ] No [ ]
If yes, explain
__________________________________________________________________
Did you ever have tubes
placed in your ears Yes
[ ] No [ ]
If yes, when and for how long
_____________________________________________________
Are any medications being
taken at this time? Yes
[ ] No [ ]
If yes, please list
________________________________________________________________
SPEECH
AND LANGUAGE HISTORY
Do you ever have difficulty
recalling familiar words while speaking? Yes [ ] No [ ]
If yes, explain
__________________________________________________________________
______________________________________________________________________________
Do you ever have difficulty
remembering a series of information such as phone numbers? Yes [ ] No [ ] If
yes, explain ____________________________________________________________
______________________________________________________________________________
Did you have problems in
learning the alphabet? Yes
[ ] No [ ]
If yes, explain __________________________________________________________________
______________________________________________________________________________
Did
you have problems in learning that certain letters correspond with certain
sounds?
Yes
[ ] No [ ]
If yes, explain
__________________________________________________________________
______________________________________________________________________________
Did you have problems
learning to read and /or spell ? Yes [ ]
No [ ]
If yes explain __________________________________________________________________
_____________________________________________________________________________
If you have reading or
spelling problems, what strategies do you use to help yourself read and spell
more effectively? ___________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Did
you receive any special tutoring or other assistance in elementary or high
school?
Yes
[ ] No [ ]
If yes, explain
__________________________________________________________________
_____________________________________________________________________________
FAMILY
HISTORY
Has any blood relative had
any history of : Yes
[ ] No [ ]
Mental illness: Yes [ ] No [ ]
Epilepsy: Yes
[ ] No [ ]
Chronic or serious medical
problems: Yes
[ ] No [ ]
Hearing difficulty: Yes
[ ] No [ ]
Speech & Language
difficulty: Yes
[ ] No [ ]
Difficulty in learning to
read or spell: Yes
[ ] No [ ]
If yes, explain
__________________________________________________________________
______________________________________________________________________________
Number
of languages spoken at home :
______________________________________________
EDUCATIONAL
HISTORY
Present school placement:
Grade or class:
_____________________ Teacher _____________________________________
Describe progress in school:
_______________________________________________________
____________________________________________________________________________________________________________________________________________________________
Job or career goals:
_____________________________________________________________
_____________________________________________________________________________
What do you hope to get from
this evaluation? _______________________________________
____________________________________________________________________________________________________________________________________________________________
Our clinical services in
reading are part of our graduate training program. We will appreciate your willingness to sign
the following statement:
“I agree to permit
University Trainees, enrolled in pertinent academic programs, to participate in
the evaluation and/or treatment procedures which will be conducted under the
supervision of the faculty of the Clinical Training Programs. In addition, I agree to permit the use of
closed-circuit television, the taking of photographs and/or motion pictures and
other recordings or similar graphic materials which are to be used for teaching
or scientific purposes.”
Date: __________________
Signed: ________________________________________________
(Parent or Guardian)