Child/adolescent (6+) Speech Pathology History Form
Download a blank fillable Child/adolescent (6+) Speech Pathology History Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Child/adolescent (6+) Speech Pathology History Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2CHILD/ADOLESCENT (6-17 YEARS)
Name: ___________________________
SPEECH-LANGUAGE PATHOLOGY HISTORY FORM
Date of Birth: ______________________
Person completing form: □Patient □Spouse □Parent/Guardian □Other-Name________________________
Address: ________________________________________________________________________________________
Telephone: (home) ______________________(work) ____________________(cell) ___________________________
Email: _________________________________________________________________________________________
Physician Name: _______________________________________
Physician Phone: ______________________
Referred by: _____________________________________________________________________________________
Reason for evaluation: _____________________________________________________________________________
Referral Needed: yes no
Insurance: __________________________________________________
Policy Number: ______________________________________________
Results will be sent to names/locations listed below if address or faxes are provided
Name
Address or Fax
Phone
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Disclosure of healthcare information will only be provided is authorized by the patient or legal guardian except
for known healthcare providers
_______________________________________________________________________________________________
Name
Relationship to patient
Address
Phone
Fax
_______________________________________________________________________________________________
Name
Relationship to patient
Address
Phone
Fax
I authorize the department to disclose healthcare information to names above. Valid for one year.
Signature of Patient Parent/Guardian ___________________________________________ Date: ___________
Printed name of Parent/Guardian: ____________________________________________________________________
Past Medical History
ADD/ADHD
YES
NO
HIV Positive
YES
NO
AIDS
YES
NO
Allergies
YES
NO
Laryngitis
YES
NO
Asthma
YES
NO
Learning Disability
YES
NO
Chicken Pox
YES
NO
Mental Retardation
YES
NO
Cancer________
YES
NO
Physical Limitations
YES
NO
Cerebral Palsy
YES
NO
Pneumonia/Bronchitis
YES
NO
Developmental Delays
YES
NO
Respiratory Disease
YES
NO
Diabetes
YES
NO
Shortness of breath
YES
NO
Ear Infections
YES
NO
Seizures
YES
NO
Epilepsy
YES
NO
Sinus Problems
YES
NO
Gastric Reflux
YES
NO
YES
NO
Head Injury
YES
NO
Speech/Lang Impairment
Hearing Loss
YES
NO
Swallowing Problems
YES
NO
Heart Problems
YES
NO
Tracheostomy tube
YES
NO
Ventilator Dependency
YES
NO
High fevers
YES
NO
Visual Impairment
YES
NO
Voice Impairment
YES
NO
Stroke
YES
NO
Brain Tumor
YES
NO
Comments/Other Medical History: _________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Speech Pathologist’s notes: ________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
CHILD/ADOLESCENT (6-17 YEARS) SPEECH-LANGUAGE PATHOLOGY HISTORY FORM - page 1 of 2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical