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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 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: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________