Patient History - Adult | EBS Children's Therapy of Georgia

Name

First Last

Date of Birth

Age

Sex

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Work or Other Phone:

Email

Marital Status:

Race/Ethnicity (select one or more):

American Indian/Alaskan Indian
Black/African American
Native Hawaiian or Other Pacific Islander
Asian
Hispanic/Latino
White
Unknown

Caregiver:

Do you have any children?

If so, is your child your caregiver?

Do you have multiple caregivers?

Emergency Contact:

Name

First Last

Phone Number

Is this number for:

Relationship to Patient:

Referral Source:

Primary Insurance:

Policy Holder Name:

Group Number

Phone Number

Secondary Insurance:

Policy Holder Name:

Group Number

Phone Number

Doctor
Counselor/Therapist
Friend
Self
Other

Insurance Information:

Reason for Visit Today

Have you received speech-language pathology services before?

If yes, when?

Where?

Have you received any other therapy services before (rehab, OT, PT)?

If yes, when?

Where?

Medical History:

List illnesses, surgeries, injuries, or medical problems. Please list date and the cause of injury, if any.

Have you experienced any muscle weakness? If so describe this experience:

Have you experienced any hearing/vision problems due to this injury?

If yes, how so?

List medications taken on a regular basis:

List known allergies:

Have you had problems with or changes in (check all that apply):

Hearing:

Wear hearing aid(s)?

Had hearing test?

If yes, when?

Vision:

Wear glasses?

Wear corrective lenses?

Had vision screened?

If yes, when?

Teeth:

Wear dentures?

Breathing:

Swallowing:

Education and Work History

Last grade completed:

Occupation before onset:

Currently working?

Hobbies/Special Interests:

Did you enjoy reading/writing before onset?

Preferred use of hand:

Language(s) Spoken

Is English your primary language?

If no, is an interpreter needed?

If no, what language(s) is/are spoken at home:

If no, what language(s) is/are spoken in your workplace/community:

Communication and Language

Please describe your speech after onset? (Respond in one words, short phrases, repeats others, etc.)

Has your speech changed after onset?

If yes, how did it change?

How do you currently communicate with others? (Verbally, use of gestures, writing, use of AAC, etc.)

How well can you follow directions, following along in conversations, remember items, etc.?

What are your biggest difficulties?

How do you solve/react to these difficulties? (Removal, anxiety, frustration, etc.)

When are you most frustrated with your communication?

Additional Information

What is your current daily routine?

Describe your personality before and after onset?

Were there any changes in mood, personality, self-care, etc?

Tell us about your goals and expectations for therapy:

Is there anything else you’d like for us to know about you?

I am granting permission for Chandler Speech and Language Services to evaluation and provide treatment recommendations as clinically necessary. Attendance is a critical factor with regard to therapy services.

I understand that if I need to cancel my appointment I must do so within 12 hours of the appointment time. If I fail to do so, Chandler Speech and Language has the right to charge a no-show fee of $50.

If I miss 3 consecutive sessions of therapy, Chandler Speech and Language has the right to place services on hold until scheduling may be resolved.

My signature indicates that, to the best of knowledge, all information provided above is accurate and current. My signature indicates I am in agreement with all policies presented above.

I acknowledge that it is my responsibility that if my insurance changes at any time or fails to cover any services, I may be responsible for any remaining balance.

Patient or Parent/Guardian Signature*

Relationship to Patient

Date