Welcome




	Euphonic will be recognized as a comprehensive rehabilitation center that serves the local community with well-trained, motivated, friendly personnel, offering services in speech-language pathology and dietary management that are affordable and accessible.


	To help our clients maximize their potential and to enhance quality of life.


	• Client-centered care: we recognize that our patients' needs come first. • Excellence: we are committed to ongoing education and continuous improvement. • Integrity: all our relationships are based on mutual respect, honesty and ethical practice. • Innovation: we encourage the discovery and development of new approaches to service delivery. • Social responsibility: we strive to share responsibility for the well being of our communities.



Name*
Name*
Date*
Date*
Date of Birth*
Date of Birth*
Age*
Age*	0
Name of person Completing this form(if other than Patient	0
Name of person Completing this form(if other than Patient
Relationship
Relationship
Primary Physician
Primary Physician
Referring Physician*
Referring Physician*
Current Medication
Current Medication

Current Living Situation

Please Describe the problem(s) for which you are seeking speech therapy.*
When and how the problem(s) begin
Have you had the problems before ? if so pease describe
What is your goal related to speech therapy?
What aspects of your life does the problem affect?	Personal Professional Social
Have you ever recieved speech therapy befor? if so, when and for what condition?

Primary Language
Second Language
Handedness	Left Right
Primary mode of communication	Oral Gestures Assitive Device
Please check if you have/had any of the following
Allergies Cancer Seizures Dizziness Stroke Lung Problems Headaches Head Injury	Thyiroid Problems High Blood Pressure Pneumonia Encephalitis Diabetes Heart Problem Asthma Others
If you checked any of the above, please give the details
Surgical history(if Any)
Recent Hospitalization (if Any)
Recent tests & Results (e.g MRI,Blood Test ,etc
Any Other details that we should aware of