History Forms & Questionaires

Helping children and adults to overcome disorders of communication for over 40 years.

For your convenience, we have made our Patient forms and questionnaires available online. Please use these to provide the information first needed by Community Speech & Hearing Center. Once you print the forms, you may complete the information and then bring the completed form to us. You may fax your information to Community, however do so only after we request it, so that we may protect your privacy. Use your back browser button to return here. You can either view the form online and print out to be completed later or download the forms with Adobe Acrobat and use your computer to complete the forms and then print out the forms completed. If you do not already have Adobe acrobat, just follow the button below for a free Adobe reader.

• Patient History Form (child) - Complete this for m for a compete patient history and background information to be used by the therapists. 
  
  
• Patient History Form (adults) - This form is used to determine patient status. You may fill out the form online and submit it directly to us, or you may print it out and complete the form and then fax or bring into our center.

• Audiology Questionnaire (Pediatric)
  
  
• Audiology Questionnaire (adults)
  
  
• Voice Disorder Questionnaire (adults)
  
  
• Supplemental Questionnaire (child) - For the non-verbal or minimally verbal child. (Please complete if your child has no words or just a few words.)