Adult Case History Form

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Client Details















Page 2

Health History





Speech & Language History















Page 3

Client Demographic Information





Consent & Electronic Signature




Please enter today's date
Financial Assistance

WASSP Rating Sheet

Please rate each of the following aspects of your stutter using a 7-point scale, 1 indicating "None" and 7 indicating "Very Severe". Please select the number which you judge best describes each aspect of your stutter. 
Stuttering Behaviors
1 (None) 2 3 4 5 6 7 (Severe)

Thoughts about stuttering
1 (None) 2 3 4 5 6 7 (Severe)
Feelings about stuttering
1 (None) 2 3 4 5 6 7 (Severe)

Avoidance due to stuttering
1 (None) 2 3 4 5 6 7 (Severe)
Disadvantage due to stuttering
1 (None) 2 3 4 5 6 7 (Severe)