Speech Therapy Plus, pllc
1421 FM 359, Suite H
Richmond, TX 77406
Adult Patient Medical History Form
Patient name: _________________________________________________________
Email address: ________________________________________________________
Phone No.: ___________________________________________________________
Are you: (circle one): Single Married Partner Separated Divorced Widowed
List members of Immediate Family
Name Age Relationship Health Problems
________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________
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:
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: ____________________________________________________________________
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) 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
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?: _________________________________________________
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:
Speech Therapy Plus, PLLC 1421 FM 359, Suite H Richmond, TX 77469 (281) 232-1900
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:________________________________
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.
SPEECH THERAPY PLUS, PLLC
1421 FM 359, SUITE H
RICHMOND, TX 77469
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.
SPEECH THERAPY PLUS, PLLC.
POLICY STATEMENT/PATIENT COPY
If you must
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.
Payment, both full private pay and co-payments, will be due upon receipt of
service. Insurance will be billed as necessary.
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.
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.
Please be on time to pick up your child. Late arrivals may involve no
post-appointment consult with your therapist and additional charges.
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.
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.
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
Please do not allow siblings in the therapy area.
I have read the above policy and agree to abide by it.
___________________________________________________________________________________ Acceptance: Missy McDonald