Form 2: Billing & Patient Case History - dietrichspeech.comdietrichspeech.com/customers/126714/Form 2 - Patient Case History.pdf · Intake Forms – Page 1 of 10 DSLS (p) 843-810-9198

Intake Forms – Page 1 of 10

DSLS ▪ (p) 843-810-9198 ▪ (f) 855-279-3149 ▪ [email protected] ▪ www.dietrichspeech.com ▪ Charleston, SC

Form 2: Billing & Patient Case History

Billing & Contact Information

Patient Name: ___________________________ DOB: ____________ Gender: _____ Social Security #:_______________

Patient Address:__________________________________________ City: ________________ State: ______ Zip: __________

Emergency Contact: ______________________ Relationship to Patient: _________________ Phone #: _______________

Parent/Guardian #1: ________________________ DOB: ____________ Gender: _____ Social Security #:____________

Address (if different from above): __________________________ City: ________________ State: ______ Zip: __________

Home Phone #: _________________ Cell Phone #: _________________ E-mail Address: ____________________________

Employer: _________________________________________ Work Phone #: _________________ Fax #: _________________

Parent/Guardian #2: ________________________ DOB: ____________ Gender: _____ Social Security #:____________

Address (if different from above): __________________________ City: ________________ State: ______ Zip: __________

Home Phone #: _________________ Cell Phone #: _________________ E-mail Address: ____________________________

Employer: _________________________________________ Work Phone #: _________________ Fax #: _________________

Primary Insurance Name: __________________________ Provider Phone # (on insurance card): __________________

Policy #: ______________________ Group #: ______________________ Policy Holder’s Name: _______________________

Policy Holder’s SSN: ______________________ DOB:________________ Relationship to Patient:______________________

Policy Holder’s Employer: _____________________________________ Employer’s Phone #: ________________________

Secondary Insurance Name: _______________________ Provider Phone # (on insurance card): __________________




Tertiary Insurance Name: ___________________________ Provider Phone # (on insurance card): __________________




Medical Diagnosis/Diagnoses:_____________________________________________________________________________

___________________________________________________________________________________________________________

_

This intake paperwork is to be completed with information provided by the parents/legal guardians/caregivers of the

patient. Please answer every section as thoroughly as possible and initial/sign where appropriate. The information

provided in this form is useful in completing a comprehensive speech-language-feeding evaluation and treatment plan

for the patient. It also allows for the accurate and efficient provision and reimbursement of services. Thank you.

If you have any questions about this document, please ask your speech-language pathologist. His/her contact information

is listed at the bottom of each page of this form. *Note: The word “parent” below refers to the patient’s legal guardian.

Dx Codes

ICD-10: _________

_________________

_________________

for office use only

mailto:[email protected]

http://www.dietrichspeech.com/

Intake – 04.23.16



Physician Contact Information

PRIMARY CARE PHYSICIAN (Referring Physician/Pediatrician – insurance will often require a prescription which we can obtain)

Patient’s Physician: ___________________________ Name of Physician’s Practice: ______________________________

Physician’s Phone #: __________________________ Physician’s Fax Number: ___________________________________

OTHER PHYSICIANS, MEDICAL SPECIALISTS (ex: Cardiologists, Neurologists, Allergists, etc.)

Provider’s Name: _____________________________ Name of Provider’s Practice: _______________________________

Provider’s Phone #: ___________________________ Provider’s Fax Number: ____________________________________





Therapeutic Services Contact Information

EARLY INTERVENTIONIST, PHYSICAL/OCCUPATIONAL/SPEECH-LANGUAGE PATHOLOGISTS, PSYCHOLOGISTS etc.

Patient does or did receive the following services: (please check all who apply and their contact information)

Speech-Language Therapy

Physical Therapy

Occupational Therapy

Early Intervention Services

Special Education Services

Counseling Services

Tutoring

ABA Therapy

Other _______________________









Child Care Providers

Babysitter/Caregiver: ________________________ Date of Birth (or approx. age): ___________ Gender: M F

Address: ____________________________________ City/State: ______________________________ Zip: _____________

Cell Phone #: ________________________________ Daytime Phone #: _________________________________________

E-mail Address: ______________________________ Contact Preference(s): _____________________________________


Intake – 04.23.16




Preschool Name: ____________________________ Preschool Phone #: ________________________________________

Preschool Address: __________________________ City/State: _______________________________ Zip: ____________

Teacher Name: _____________________________ Daytime Phone #: _________________________________________

E-mail Address: ______________________________ Contact Preference(s): _____________________________________

Additional Information

Name of Person(s) with Legal Custody of Minor Patient: _______________________________________________________

Patient’s Race/Ethnic Group: (race may affect the prevalence/other factors of some conditions)

Caucasian, Non-Hispanic

Native American

Hispanic

Asian or Pacific Islander

African-American / African

Other _______________________

Patient lives with: (please check all primary caregiver(s) who apply)

Birth Parents

One Parent

Adult Sibling

Adoptive Parents

Parent & Step-Parent

Other Family Relative(s)

Foster Parents

Grandparents

Other _______________________

Who cares for your child during a typical day? For approximately how long? (please complete all who apply)

Parents/LGs – # Hours: _______

Grandparents – # Hours: _____

Babysitter(s) – # Hours: _______

Sibling (<18yrs.) – # Hours: _____

Sibling (adult) – # Hours: ______

Other Relative – # Hours: _____

Preschool – # Hours:__________

School – # Hours:_____________

Other: ________ – # Hours: ____

Languages Spoken Around Child

Is there a language OTHER THAN English spoken around the child on a regular basis? Yes No

If yes, please complete the below chart for all languages (other than English) spoken around the child.

What

language(s)

is/are spoken?

Who speaks the

language at

home?

Does the child

speak the

language?

Does the child

understand the

language?

Which is

spoken the

most often?

Which one

does the

child prefer?

1 Yes No Yes No Most: _________

2nd Most: ______

2 Yes No Yes No

3 Yes No Yes No

Other Household Members

Please list all people currently living in the home with the child. Name Age Relation to Child Name Age Relation to Child

1 5

2 6

3 7

4 8





B & PCH – 04.23.16

Form 2: Billing & Patient Case History – Page 4 of 10


Physiological Information

Patient’s Current Health Status: Excellent Good Fair Poor

Patient’s Current Weight: __________________________ Child’s Current Height: _____________________________

Date of most recent physical examination or doctor’s visit: ____________________

Notes: _____________________________________________________________________________________________________

____________________________________________________________________________________________________________

Family History

Biological Parents

Is there a parental history of speech-language-feeding delays or disorders?

Mother

Yes / Type of Disorder: __________________________

No

Father

Yes / Type of Disorder: __________________________

No

Other Biological Siblings with Speech-Language-Feeding Problems

First Name

Age Child’s

Gender

Biological

Sibling? Speech/Language/Feeding/Hearing Problems?

Please name or describe the delay/disorder if answered “yes.”

M F Y N Y N

M F Y N Y N

M F Y N Y N

M F Y N Y N

M F Y N Y N

Additional Family Members with Speech-Language-Feeding Problems

Please list any additional family history relevant to speech and language disorders.

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

Family Medical History

Have any members of the family (aunts, uncles, grandparents, siblings, cousins) had any of the following?

Condition Yes / No Who (if “yes”)

Condition Yes / No Who (if “yes”)

Allergies Yes No Lead Poisoning Yes No

Birth Defect Yes No Learning Disability Yes No

Genetic Syndrome Yes No Mental Health Problems Yes No

Hearing Loss Yes No Mental Retardation Yes No



B & PCH – 04.23.16



Heart Problems Yes No Muscle Problems Yes No

Lead Poisoning Yes No Seizures / Epilepsy Yes No

Vision Problems Yes No Other _________________ Yes No

Comments / Important Notes:

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

General Home/Community Life Questions

1. Is the family undergoing any stress currently? Yes_____________________________________________ No

2. What is the general method of discipline used in your family? _________________________________________

3. How well does the child get along with other family members? _______________________________________

4. Does your child have playmates (other than siblings)? Yes: Older Younger Same age No

5. How does the playmate like to spend his/her free time? ______________________________________________

6. How do you and your child like to spend free time together? _________________________________________

7. Does dad/legal guardian #1 work outside the home? Yes / How many hours? ______________ No

8. Does mom/legal guardian #2 work outside the home? Yes / How many hours? _______________ No

9. How does the child react when left with a sitter? _____________________________________________________

Prenatal and Birth History

1. Was anything unusual about the pregnancy (illnesses, accidents, medications, conditions)? Yes No

____________________________________________________________________________________________________

____________________________________________________________________________________________________

2. Length of Pregnancy: _________________ Duration of Labor: ____________ Birth Weight: ______________

3. Was child born prematurely (before 37 weeks)? Yes No If yes, how many weeks early? ___________

4. Nature of Delivery: Vaginal C-section Breech Head / feet first Other ____________________

5. Were there any unusual conditions or complications during labor and delivery? Yes No

____________________________________________________________________________________________________

6. Child’s Condition at Birth: Jaundiced Blue Breathing Other _________________________________

7. Age of the mother at child’s birth: _________________ Age of the father at child’s birth: _________________

8. Did the baby go home with his/her mother from the hospital? Yes No

9. If the baby stayed in the hospital for an extended time, please briefly answer the following questions:

How long did the baby stay?__________ Why did the baby stay?___________________________________

10. Which of these best describes your child as a baby: Silent Quiet Average Noisy Not sure

11. Is there anything else you would like to share about your child’s prenatal and/or birth history?

____________________________________________________________________________________________________



B & PCH – 04.23.16



Developmental History

Patient Medical History

Please check if any of the following signs/symptoms are present now or have been experienced in the past.

asthma

allergies

bleeds or bruises

breathing difficulties

chicken pox

ear infections (#_______)

ear tubes

encephalitis

eye or vision problems

flu

frequent colds

head injury

high fevers

measles

meningitis

mumps

muscle pain/weakness

poor appetite

scarlet fever

seizures

sinusitis

skin rashes

sleeping difficulties

thumb/finger sucking habit

tonsillectomy

tonsillitis

uncontrollable hunger

1. Are there any other serious injuries or surgeries the patient has had? If yes, please explain.

Yes________________________________________________________________________________________

No

2. Are there any upcoming surgeries or procedures scheduled? If yes, please explain.

Yes________________________________________________________________________________________

No

3. Is your child currently (or recently) under a physician’s care? If yes, please explain.

Yes_________________________________________________________________________________________

No

4. Please list any medications your child takes regularly:

__________________________________________________________________________________________________

Feeding Development

1. Breast / How long? _____________________ Weaned at what age? ___________________

2. Bottle / How long? _____________________ Weaned at what age? ___________________

3. Formula? Yes No Weaned at what age? ___________________

Type(s) of formula: ___________________________________________________________________________

4. Any problems related to sucking, swallowing chewing or feeding? Yes No If yes, please describe:

___________________________________________________________________________________________________

5. Did/does your child suck a pacifier, thumb, fingers, etc.? Yes ________________________________ No

6. Was/is the child’s weight gain unusual in any way? Yes ______________________________________ No

7. General impression of child’s feeding development: Delayed Average Advanced

Does your child:

8. choke on food and/or liquids? Yes No

9. currently put objects in mouth? Yes No

10. allow brushing of his/her teeth? Yes No

11. have major food aversions? Yes No



B & PCH – 04.23.16



Speech, Language and Hearing Development

Please give the approximate age at which your child reached the below milestones independently. If your

child has not yet displayed a skill, please check the “not yet demonstrated/NYD” or “no” box as appropriate.

1. Noticed noises: ___________ NYD

2. Cooed: ___________ NYD

3. Babbled: ___________ NYD

4. Said first words: ___________ NYD

5. Put 2 words together: ___________ NYD

6. Spoke in short sentences: ________ NYD

7. Does child have any hearing impairments? Yes No If yes: right ear left ear both ears

8. Has your child ever had a speech evaluation or screening? Yes No If yes, what were you told?

_________________________________________________________________________________________________

9. Has your child ever had a hearing evaluation or screening? Yes No If yes, what were you told?

_________________________________________________________________________________________________

10. Has your child ever had a vision evaluation or screening? Yes No If yes, what were you told?

_________________________________________________________________________________________________

11. Is your child aware of, or frustrated by, any speech/language difficulties? Yes No If yes, please

describe. _______________________________________________________________________________________

_________________________________________________________________________________________________

12. What do you see as your child’s most difficult problem in the home? _______________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

13. What do you see as your child’s most difficult problem in the school? _____________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

Does your child:

14. repeat sounds, words or phrases over and over? Yes No

15. understand what you are saying? Yes No

16. retrieve/point to common objects upon request (ball, cup, shoe)? Yes No

17. follow simple directions (“shut the door” or “get your shoes”)?Yes No

18. respond correctly to yes/no questions (factual and for basic wants/needs)? Yes No

19. respond correctly to who/what/where/when/why questions? Yes No

Please check all that apply. Your child currently communicates using:

20. body language/simple signs: Yes No

21. sounds (vowels, grunting): Yes No

22. single words (ex: shoe, up): Yes No

23. utterances of 2-4 words: Yes No

24. sentences of 5+ words: Yes No

25. Other: ________________________________



B & PCH – 04.23.16



Please answer the following questions by checking the appropriate box.

26. Is your child’s speech understandable to less/unfamiliar listeners? Yes No

27. Approximately how many words are in your child’s vocabulary? 1-10 11-25 26-50 51-75

76-100 101-150 151-200 201-250 251-300 301-400 401-500 500+ I don’t know

28. Does your child stammer or stutter when speaking? Yes No

29. Is your child’s voice quality hoarse, nasal, too loud, too soft, etc.? Yes_______________________ No

30. General impression of child’s speech, language and hearing development:

Delayed Average Advanced

Behavioral Development

Please check all of the following behavioral characteristics that your child demonstrates.

attentive

cooperative

destructive/aggressive

easily distracted/short attention

easily frustrated/impulsive

inappropriate behavior: _______________

plays alone for reasonable time period

poor eye contact

restless

self-abusive behavior: _________________

separation difficulties

stubborn

willing to try new activities

withdrawn

31. Do you have any general concerns with your child’s behavioral development (ex: sleep, play,

social, diet, etc.)? If yes, please describe: ________________________________________________________

_________________________________________________________________________________________________

Motor Development

Please give the approximate age at which your child reached the below milestones independently. If your

child has not yet displayed a skill, please check the “not yet demonstrated/NYD” or “no” box as appropriate.

1. smiled: ___________ not yet demonstrated

2. held head up: ___________ NYD

3. followed objects with eyes: _________ NYD

4. sat unsupported: ___________ NYD

5. tolerated tummy time: ___________ NYD

6. rolled over: ___________ NYD

7. crawled: ___________ NYD

8. pulled to stand: ___________ NYD

9. walked: ___________ NYD

10. ran: ___________ NYD

11. jumped: ___________ NYD

12. toilet trained: ___________ NYD

13. fed self with fingers: ___________ NYD

14. fed self with spoon: ___________ NYD

15. drank from cup: ___________ NYD

16. drank from straw: ___________ NYD

17. used utensils: ___________ NYD

18. grasped crayon/pencil: ___________ NYD



B & PCH – 04.23.16



19. scribbled: ___________ NYD

20. colored: ___________ NYD

21. cut with scissors: ___________ NYD

22. wrote: ___________ NYD

23. dressed/undressed self: ___________ NYD

24. bowel control: Yes No

25. bladder control – daytime: Yes No

26. bladder control – nighttime: Yes No

27. Does your child fall or lose balance easily? Yes _______________________________________________ No

28. Does your child use his/her: Left hand Right hand Both Neither ____________________________

29. General impression of child’s overall motor development: Delayed Average Advanced

30. Child’s current activity level: Seems average Overactive Passive Other___________________

Sensory Processing Development

Please check all of the following sensory processing characteristics that your child demonstrates.

drools: never sometimes often always

seems clumsy or awkward

seems to be in constant motion

seems to fatigue or tire easily or to have generally weak strength

sensitive or overly responsive to sounds or noises (ex: seems to overreact to noises)

sensitive or overly responsive to tastes or smells (ex: loves or hates sour, sweet, or salty)

sensitive or overly responsive to touch (ex: craves hugs, dislikes certain clothing items or textures)

Emotional Signs and Symptoms

Please check all of the following emotional signs and symptoms that your child demonstrates.

appears to be well adjusted

bites nails

difficult to discipline

easily upset

gets along well with others

has difficulty sleeping

has frequent nightmares

has reasonable fears

is destructive

lives “in his/her own world”

overly active

overly quiet

prefers to be alone

sucks thumb

temper tantrums

other: _____________________

Adaptive Equipment

Please check if your child is presently using any of the following items.

AAC device

Braces

Glasses/contacts

Hearing aids

Positioning devices

Walker

Weighted jacket

Wheelchair

Other: _________________

________________________

________________________

________________________

__________________________

__________________________

__________________________



B & PCH – 04.23.16



School History

If your child is in school (K-12), please answer the following questions.

1. Name of school: ____________________________________________________________________________________

School Phone #: __________________________________

School Fax #: _____________________________________

2. Current Grade in school: __________

Repeated a grade(s)? Yes _______________________________________________________________ No

3. Teacher Name(s): __________________________________________________________________________________

E-mail(s): ________________________________________________________________________________________

Phone #(s): _____________________________________________________________________________________

4. What are your child’s strengths and/or best subjects? _________________________________________________

____________________________________________________________________________________________________

5. Is your child having difficulty with any subjects? ______________________________________________________

____________________________________________________________________________________________________

6. Is your child receiving help in any subjects? __________________________________________________________

____________________________________________________________________________________________________

7. Do problems with your child’s speech, language, hearing, behavior, emotions, etc. negatively affect

his/her performance at school? Yes __________________________________________________________ No

8. Name(s) of people who have been particularly helpful at school: _____________________________________

Patient Preferences

Any information you can provide about your child’s preferences related to activities, hobbies, sports, toys,

games, TV shows, movies, music, foods, etc. can be useful when customizing their therapy sessions.

Your Comments, Questions, Suggestions, Goals

How can we help you and your child? Please provide your concerns, suggestions, goals, etc. for your child.



Documents

Form 2: Billing & Patient Case History - dietrichspeech.comdietrichspeech.com/customers/126714/Form 2 - Patient Case History.pdf · Intake Forms – Page 1 of 10 DSLS (p) 843-810-9198