Download Speech Therapy Plus, pllc

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
Divorced
Married
Widowed
Partner
Separated
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:
Has your vision ever been tested?
Do you wear glasses?
Do you think you may have a vision problem?
Has your hearing ever been tested?
Do you wear a hearing aid?
Do you think you may have hearing problem?
___ Yes
___ Yes
___ Yes
___ Yes
___ Yes
___ Yes
___ No
___ No
___ No
___ No
___ No
___ 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) 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 is high pitched
Low pitched
Too loud
Lacks volume
Fast rate of speech
Slow rate of speech
Sounds gravelly
Hesitant
___
___
___
___
___
___
___
___
Voice tires easily
Voice breaks
“Lump in the Throat” feeling
Mispronunciation
Difficult to understand when you talked
Difficult to understand others’ speech
Stuttering
Other
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
(check all that apply)
___
___
___
___
___
___
___
___
Elementary
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:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________