Speech Therapy Plus, pllc 1421 FM 359, Suite H Richmond, TX Phone: (281) Fax: (281)

Transcription

1 Speech Therapy Plus, pllc 1421 FM 359, Suite H Richmond, TX Phone: (281) Fax: (281) Adult Patient Medical History Form Patient name: Address: address: Phone No.: Family: Are you: (circle one): Single Married Partner Separated Divorced Widowed List members of Immediate Family Name Age Relationship Health Problems Work History: Are you currently employed outside the home? Yes No. If not, are you, retired disabled Present type of work: At work, are you exposed to: harmful toxins heavy lifting extreme temperatures undue stress other potential hazards Current Medical History: Are you having any medical problems?: yes no; If yes, please explain:

2 Has your vision ever been tested? Yes No Do you wear glasses? Yes No Do you think you may have a vision problem? Yes No Has your hearing ever been tested? Yes No Do you wear a hearing aid? Yes No Do you think you may have hearing problem? Yes No Family History: If patient or family member has or has had any of the following problems, mark as indicated below and explain in the space provided: P-Patient M-Mother F-Father GM-Grandmother GF-Grandfather A-Aunt U-Uncle chronic illness: _ allergies: speech problem: hearing problem: swallowing problems: asthma/lung problems: _ respiratory infections: tuberculosis: immunity problems/hiv: high blood pressure:_ heart attack: _ mental retardation: _ drug/alcohol use: stroke: cancer: seizures: _ mental illness: other: Additional Comments: Please list below all illnesses, injuries and operations. You may list up to six. 1) Type: _ Age: Complications: Treatment: Physician: _ 2) Type: _ Age: Complications: Treatment: Physician: _

3 3) Type: _ Age: Complications: Treatment: Physician: _ 4) Type: _ Age: Complications: Treatment: Physician: _ 5) Type: _ Age: Complications: Treatment: Physician: _ 6)Type: _ Age: Complications: Treatment: Physician: _ List all Present Physical Disabilities: Current Medications and Purposes: Medication Allergies? Yes No; If yes, please list medications and their reactions: Description of Speech and/or Hearing Problems: Check any of the following which describes difficulties you presently have: Often hoarse Voice tires easily Voice is high pitched Voice breaks Low pitched Lump in the Throat feeling Too loud Mispronunciation Lacks volume Difficult to understand when you talked Fast rate of speech Difficult to understand others speech Slow rate of speech Stuttering Sounds gravelly Other Hesitant

4 If other above symptoms, please explain: Has anyone ever looked at your vocal chords and/or soft palate?: Yes No What was found?: Have you ever had a modified barium swallow test: Yes No What were the results?: _ School History: Education Level Elementary (check all that apply) Junior High Senior High Vocational Some College College Degree Graduate Level/Higher Other If other, please explain: Social History: Hobbies: Sports: If there is any additional information that you feel would be important for your provider to be aware of, please explain:

5 Speech Therapy Plus, PLLC 1421 FM 359, Suite H Richmond, TX (281) Speechtherapyplus@comcast.net Patient Information: Last Name:_ First Name:_ Middle Name:_ Address: Apt. # City: State: Zip Code: _ Home Phone: Work Phone: Cell Phone:_ Fax:_ Other Phone:_ Birth Date of Patient:_ Sex (circle one): M F SSN of Patient:_ Primary Insurance Information: Insurance Company:_ Subscriber #: Group #: Name of Insured: D.O.B. of Insured: Employer of Insured:_ Work Phone: Work Status (circle one): Full Time Part Time Retired Unemployed Secondary Insurance Information: Insurance Company: Subscriber #: Group #:_ Name of Insured: D.O.B. of Insured:_ Employer of Insured:_ Work Phone: Address of Employer: Work Status (circle one): Full Time Part Time Retire Unemployed Emergency Contact Information: Name:_ Home #:_ Cell #: Who may we thank for referring you? Name of referring Physician (if applicable): Address of referring Physician: Contact phone # of referring Physician:

6 Current Physician/Pediatrician: Address: Phone No: By signing this form, I am authorizing Speech Therapy Plus, PLLC to bill my insurance company. I understand that I am financially responsible for charges, whether or not paid for by my insurance. I hereby authorize the release of all information necessary to secure payments of benefits. I authorize the use of this signature on all insurance submissions. Signature: Date:

7 SPEECH THERAPY PLUS, PLLC 1421 FM 359, SUITE H RICHMOND, TX Phone: (281) Fax: (281) SERVICE NEEDS SURVEY Please answer the following questions in order to serve you better. 1. What is the main area of concern you have for your child? (i.e., speech, swallowing, oral motor skills, language skills, etc.) 2. What is the best time for your child to be seen? 3. Do you prefer a set schedule or flexible schedule? 4. Does your child have specific things that he/she really likes/dislikes? 5. Is there anything else you would like for me to know about your child ( things that upset him, things he will work for, etc.) I want your child speech therapy to be as productive and pleasant as possible. I look forward to working with both of you.

8 Please initial: SPEECH THERAPY PLUS, PLLC. POLICY STATEMENT/PATIENT COPY 1. If you must CANCEL a session, please do so AT LEAST 4 HOURS IN ADVANCE, otherwise you will be charged in full for unexcused absences. Please make every attempt to reschedule missed sessions. Please confirm appointments with your therapist if you have any questions regarding your therapy schedule. 2. Payment, both full private pay and co-payments, will be due upon receipt of service. Insurance will be billed as necessary. 3. I understand that I will be responsible for any/all charges for provided services in the case that insurance claim submissions are denied for any reason. 4. It is very important that you adhere to your appointment time. Late arrivals for appointments will be seen for the remaining period of time for their allotted time schedule. You will still be charged for the full scheduled time. 5. Please be on time to pick up your child. Late arrivals may involve no postappointment consult with your therapist and additional charges. 6. Therapy sessions will consist of a 5 minute consult with your therapist following session. For example, for a 30 minute session, your child will have a 25 minute session, with a five minute discussion of progress. 7. Progress reports with a treatment plan and goals are written every six months. Families are billed for one hour of service for these documents. Families are billed for onehalf hour of service for the initial treatment plan, which is written soon after enrollment in therapy. If your insurance company requests reports at more frequent intervals, there may be additional charges. 8. You may be required to remain at the office while your child is in therapy. 9. The waiting area is equipped with toys and books for your child s use while in therapy as well as for anyone s use while in the waiting area. Please keep the waiting area reasonably quiet. 10. Please do not allow siblings in the therapy area. I have read the above policy and agree to abide by it. _ Signature Date Acceptance: Missy McDonald

9 Speech Therapy Plus, pllc 1421 FM 359, Suite H Richmond, TX Phone: (281) Fax: (281) Patient Name: Date: _ As required by Privacy Regulations, I hereby acknowledge that I have received a copy of Speech Therapy Plus Notice of Privacy Practices on the date listed above. I understand that if I have questions or complaints regarding my privacy rights, that I may contact Speech Therapy Plus. I further understand that Speech Therapy Plus will offer me updates to this Notice of Privacy Practices should it be amended, modified, or changed in any way. Patient or Representative (please print): Patient or Representative Signature: Patient refused to sign _ Patient was unable to sign because:

10 Speech Therapy Plus, pllc 1421 FM 359, Suite H Richmond, TX Phone: (281) Fax: (281) Consent for Treatment Form I, (patient/guardian) on this day, (date) authorize Speech Therapy Plus, pllc. to evaluate and/or provide speech therapy treatment and services for (patient). Consent for Release of Information I, (patient/guardian) on this day, (date) authorize Speech Therapy Plus, pllc., it s provider(s) and/or other designated office staff, to release and obtain clinical information for _ (patient) as it relates to the treatment, authorization for treatment and for the purposes of insurance reimbursement. I understand that this information may be shared with insurance companies, physicians offices and/or other required medical/educational offices as it relates to the treatment of the above patient.