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

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Speech Therapy Plus, pllc

1421 FM 359, Suite H

Richmond, TX 77406

Phone: (281)-232-1900

Fax: (281)-232-1939

Adult Patient Medical History Form

Patient name: _________________________________________________________

Address: ____________________________________________________________

____________________________________________________________

Email 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:

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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: __________________________________

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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

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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:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

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Speech Therapy Plus, PLLC 1421 FM 359, Suite H Richmond, TX 77469 (281) 232-1900

Speechtherapyplus@comcast.net

Patient Information:

Last Name:______________________ First Name:______________________ Middle Name:_________________________

Address:_________________________________________ Apt. #___________ City:_______________________________________ State:__________________ Zip Code:___________________________________

E-mail:_____________________________________________________________ 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:________________________________

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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.

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SPEECH THERAPY PLUS, PLLC

1421 FM 359, SUITE H

RICHMOND, TX 77469

Phone: (281)232-1900

Fax: (281)232-1939

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.

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SPEECH THERAPY PLUS, PLLC.

POLICY STATEMENT/PATIENT COPY

Please initial:

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

post-appointment 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

one-half 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

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Speech Therapy Plus, pllc

1421 FM 359, Suite H

Richmond, TX 77406

Phone: (281)-232-1900

Fax: (281)-232-1939

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

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Speech Therapy Plus, pllc

1421 FM 359, Suite H

Richmond, TX 77406

Phone: (281)-232-1900

Fax: (281)-232-1939

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.

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