General Application Form - Dahousie University - Canada

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General Application Form
(Please note that all information will be considered confidential)
Program Date: _________________________
Alternate Date: ________________________
GENERAL INFORMATION
Name of Applicant:
___________________________________________________
Address:
______________________________________________________________
Street
______________________________________________________________
City
Province/State
Postal Code/Zip
E-mail:
_____________________________________________________
Home Phone:
(____)______________
Work Phone: (____)__________
Date of Birth:
___________________
Sex:
M ___ F ___
M
D
Y
PERSONAL INFORMATION
Do you live alone?
Yes
No
If no, with whom do you live? (name & relationship) _________________________
____________________________________________________________________________
Do you have children?
Yes
No
If yes, provide names and ages:
________________________ ____________________________ _________________________________
____________________ ________________________ ____________________________
Do you have grandchildren?
Yes
No
If yes, provide names and ages:
________________________ ____________________________ _________________________________
____________________ ________________________ ____________________________
Provide the names of people with whom you communicate on a regular basis:
1.
___________________________ Relationship ___________________________
2.
___________________________ Relationship ___________________________
3.
___________________________ Relationship ___________________________
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General Application Form
(Please note that all information will be considered confidential)
Program Date: _________________________
Alternate Date: ________________________
GENERAL INFORMATION
Name of Applicant:
___________________________________________________
Address:
______________________________________________________________
Street
______________________________________________________________
City
Province/State
Postal Code/Zip
E-mail:
_____________________________________________________
Home Phone:
(____)______________
Work Phone: (____)__________
Date of Birth:
___________________
Sex:
M ___ F ___
M
D
Y
PERSONAL INFORMATION
Do you live alone?
Yes
No
If no, with whom do you live? (name & relationship) _________________________
____________________________________________________________________________
Do you have children?
Yes
No
If yes, provide names and ages:
________________________ ____________________________ _________________________________
____________________ ________________________ ____________________________
Do you have grandchildren?
Yes
No
If yes, provide names and ages:
________________________ ____________________________ _________________________________
____________________ ________________________ ____________________________
Provide the names of people with whom you communicate on a regular basis:
1.
___________________________ Relationship ___________________________
2.
___________________________ Relationship ___________________________
3.
___________________________ Relationship ___________________________
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MEDICAL HISTORY
What was the cause of your communication problem?
Stroke ____
Accident ____
Other (please describe)________________
Date ___________________
Do you have any physical weakness or paralysis as a result of your
illness/accident?
Yes
No
If yes, describe ___________________________________
Were you right or left handed before the present problem?
Right
Left
Do you have any swallowing problems as a result of your illness/accident?
Yes
No
If yes, describe ___________________________________
Do you have any longstanding health conditions/problems?
Yes
No
If yes, describe ___________________________________
Please list any medications & dosages you are currently taking:
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
_________________________
COMMUNICATION HISTORY
Did you have any speech or hearing problems before your
stroke/accident/illness?
Yes
No
If yes, describe _________________________________
Is there any history of speech, language or hearing problems in your family?
Yes
No
If yes, name your relationship to the person and describe the problem:
____________________________________________________________________________________________________________
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HEALTH AND PERSONAL CARE
Are you on any special diet?
Yes
No
If yes, describe ____________________________
Do you have any allergies?
Yes
No
If yes, what are they? _______________________
Are you independent for all transfers?
Yes
No
If no, describe ________________________________________________________
Are you ambulatory?
Yes
No
If yes, how far can you go independently?
____ 25 meters or less ____ 25-100 meters ____ 100 meters or more
_
Do you regularly use a wheelchair?
Yes
No
If yes, do you do so independently?
Yes
No
Do you have special transportation requirements?
Yes
No
If yes, describe ________________________________________________________
Do you wear glasses?
Yes
No
If yes, why do you wear glasses?
reading
distance
both
Describe any other visual difficulties that you have ___________________________
Have you had your hearing tested?
Yes No
When? ____________________
Do you wear a hearing aid?
Yes
No
If yes, for how long have you worn the aid? ___________________________
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EMPLOYMENT HISTORY
Occupation ______________________ Workplace ____________________________
Past Occupations
___________________________________________________________________________
Were you employed at the time of your stroke/accident/illness?
Yes
No
Are you on a leave of absence? Yes
No
How long? _______
Are you retired?
Yes
No
How long? _______
Are you retired due to your stroke/accident/illness?
Yes
No
EDUCATIONAL HISTORY
What was highest grade level you completed in school?______________________
Did you attend university/college?
Yes
No
School Name
Degree _________________________
Is English your first language?
Yes
No
Were you ever fluent in any other language(s)?
Yes
No
If yes, what languages? ___________________________________________________
LEISURE TIME
Do you consider yourself an active person (you enjoy conversation and
participating in activities with others)?
Yes
No
What do you do in an average day?
_____________________________________________________________________________
_____________________________________________________________________________
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Please provide information about health services which you received or are
currently receiving. Please ensure that contact information is current.
List hospitals/rehabilitation centers where you were a patient:
1. ________________________________ approx. dates ___________________
2. ________________________________ approx. dates ___________________
3. ________________________________ approx. dates ___________________
Have you had any of the following tests?
CT scan- Yes
No
If Yes, Hospital name: ____________________________
MRI -
Yes
No
Hospital name: ____________________________
EEG -
Yes
No
Hospital name: ____________________________
PET scan- Yes
No
Hospital name: ____________________________
SPEECH-LANGUAGE ASSESSMENT/THERAPY
Dates
____________________________________________________________________________
Clinician ____________________________________________________________________________
Facility
____________________________________________________________________________
Address ____________________________________________________________________________
Street
____________________________________________________________________________
City
Province/State
Postal Code/Zip
Phone
(_____) ____________________ E-mail _________________________________________
PHYSIOTHERAPY
Dates
____________________________________________________________________________
Clinician ____________________________________________________________________________
Facility
____________________________________________________________________________
Address ____________________________________________________________________________
Street
____________________________________________________________________________
City
Province/State
Postal Code/Zip
Phone
(_____) ____________________ E-mail _________________________________________
OCCUPATIONAL THERAPY
Dates
____________________________________________________________________________
Clinician ____________________________________________________________________________
Facility
____________________________________________________________________________
Address ____________________________________________________________________________
Street
____________________________________________________________________________
City
Province/State
Postal Code/Zip
Phone
(_____) ____________________ E-mail _________________________________________
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