Voice evaluation registration packet

Inova Loudoun Pediatric & Adult Rehabilitation Center
VOICE CASE HISTORY FORM
44035 Riverside Parkway
Suite 500A
Leesburg, VA 20176
Phone: (703) 858-6667
Fax: (703) 858-6665
We ask that you please fill out this form as completely as possible. This information will assist us in providing a safe and effective
treatment program. ALL INFORMATION IS STRICTLY CONFIDENTIAL. PLEASE INFORM US IF AT ANY TIME THIS
INFORMATION CHANGES.
**PLEASE NOTE: AFTER COMPLETION, PLEASE RETURN THIS FORM, ALONG WITH ANY OTHER PERTINENT
ACADEMIC and/or MEDICAL REPORTS (e.g. Previous therapy evaluations, Hospital discharge summaries, etc.) TO THE
CENTER. AS SOON AS WE RECEIVE THIS INFORMATION WE WILL CONTACT YOU TO SCHEDULE AN
APPOINTMENT. You can fax this completed form to 703-858-6665 or mail/drop off to the address above.
We thank you in advance for your time and effort in completing this form.
Form Completed by: _____________________________________Relationship to client: ________________________________
(Please Print or Type)
I. CASE HISTORY INFORMATION Today’s Date
Client’s Name ______________________________
Preferred Name _____________________________________
Date of Birth ______________ Age ______ Sex ______ SSN: ________________________________________
Marital Status: S M D W
Ethnicity: African American – Asian – Caucasian – Hispanic/Latino
Other: ______________________________________________________________________
Please list members/ages of those living in the home with patient: __________________________________________________
_______________________________________________________________________________________________________
If English is your second language, please list language spoken in the home: __________________________________________
At what age English was learned? ______________________________ Do you need an interpreter? ___YES
___NO
Address: _________________________________________________________________________________________________
City: ___________________________________________ State: ________________________ Zip: ___________________
Telephone: (Home) ______________________ (Work) ______________________ (Cell) _______________________________
E-Mail Address: ___________________________________________________________________________________________
Employer: _________________________________________ Employer Phone: ________________________________________
Name of Spouse: __________________________________________________________________________________________
Spouse Employer: __________________________________ Employer Phone: ________________________________________
Primary Care Physician: _____________________________________________________________________________________
How did you hear about us? (Please circle one)
Word of mouth Insurance Provider Internet Phone book/yellow pages Other_________________________
If Physician: (Please list name) _______________________________________________________________________________
Address: _________________________________________________________________________________________________
1

II. EDUCATION/SOCIAL HISTORY
Highest level of schooling completed (please circle one):
Grade School High School Trade School College Graduate Doctorate Other: ___________
Are you currently employed? ___YES ___NO Do your symptoms interfere with your ability to do your job? ___YES ___NO
Current/Past Occupation: ___________________________________________________________________________________
Are you retired? ___YES
___NO If so, for how long? ________________________________________________________
If student, please list grade, school attending, and teacher/speech-language pathologist:___________________________________
_________________________________________________________________________________________________________
Name of school / daycare provider (in home/out of home):__________________________________________________________
Please list any sports/community activities or hobbies you enjoy: __________________________________________________
_________________________________________________________________________________________________________
III. MEDICAL HISTORY
What symptoms/problems led you to request this evaluation?
__________________________________________________________________________________________________________
Date of onset (month, day, year problem was first noticed): _________________________________________________________
Has this problem improved/deteriorated since the onset? Please Explain:
__________________________________________________________________________________________________________
Have you been treated for this problem before? ___YES
___NO
If yes, state where: _____________________________________ Approximately when: ________________________
Treatment given: ________________________________________________________________________________
Was the treatment successful? ___YES
___NO
Have you had surgery/medical treatment for this problem before? ___YES
___NO
If yes, please list the approximate date and type of surgery/medical treatment: ___________________________________________
List any other major medical illness or surgery that has occurred (may attach separate sheet, if needed)_______________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Are you currently taking ANY medications? ___YES
___NO
If YES, please complete the following regarding medications: (Please use back of form if necessary)
MEDICATION REASON FOR TAKING SIDE EFFECTS
MEDICATIONS
EXPERIENCED
___________________________ ________________________ _______________________
___________________________ ________________________ _______________________
___________________________ ________________________ _______________________
___________________________ ________________________ _______________________
___________________________ ________________________ _______________________
2

(MEDICAL HISTORY (continued)
Please list any vitamins/supplements you may be taking, along with reason for taking:
___________________________________________________________________________________________________
________________________________________________________________________________________________
If patient is a child, are there any significant birth or developmental problems to be noted? If so, please list.___________________
__________________________________________________________________________________________________________
Are you on an altered diet? (e.g. soft food, PEG-tube, thickened liquids) ___YES ___NO
If YES, please describe: ______________________________________________________________________________________
Are you currently (or recently) under a specialty physician’s care? ___Y ___N If yes, why? ____________________________
________________________________________________________________________________________________
Is there a family history of allergies? ___Y ___N If yes, please list. _____________________________________________
Please circle any of the following you have experienced:
Facial Numbness Hoarseness High Fevers/Chills/Sweats
Reflux/Heartburn Pneumonia Injury/Falls
Fatigue Unexpected weigh gain/loss Nausea/Vomiting
Head Trauma Weakness Night Pain
Bowel Dysfunction Urinary Frequency Changes Stuttered Speech
Orientation problems Difficulty with Judgment Maintaining Topic of Conversation
Memory Focusing/Attending Vision Problems
Reading Writing Slurred Speech
Word Finding Problem Solving Expressing Thoughts
Following Directions Coughing/Choking Throat Pain
Swallowing/Chewing
Radiation/Chemo Therapy
If you have had treatment for any of the above symptoms, please describe: ____________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
Please circle all that apply:
Aids/HIV Drug/Alcohol Abuse Psychiatric Treatment
Allergies Emphysema Rheumatic Fever
Anemia Fainting Rheumatic Heart Disease
Asperger’s Fractures Seizures /Epilepsy
Arthritis Glaucoma Shortness of Breath
Asthma Heart Disease/Atrial Fibrillations Sinusitis
Back Trouble Heart Attack Stomach Ulcers
Bipolar Disorder Heart Murmur Stroke/TIA’s
Bleeding Disease Hepatitis Swelling of Hands/Feet
Bronchitis Herpes/Shingles Thyroid Disease
Cancer High Blood Pressure Tuberculosis
Chest Pain Jaundice Diabetes
Congestive Heart Failure Kidney Disease Motor Vehicle Accident
Congenital Heart Defect Learning Disabled Other ________________________
Convulsions Liver Disease Other ________________________
Depression
Mental Retardation
3

(MEDICAL HISTORY (continued)
Do you use tobacco? ___YES ___NO
If YES, amount: ________________________________________________________
Drink alcoholic beverages? ___YES ___NO If YES, amount: ___________________________________________________
Drink caffeinated beverages? ___YES ___NO If YES, amount: __________________________________________________
Are there any incidences of any of the following conditions for this patient or patient’s close family relatives (mother or father’s
side?) (Please check all that apply) Patient Relative Relationship to Patient
1. Speech problems _____ _____ ____________________________________
2. Hearing problems _____ _____ ____________________________________
3. Learning disabilities _____ _____ ____________________________________
4. Seizures/convulsions _____ _____ ____________________________________
5. Gastroesophageal Reflux _____ _____ ____________________________________
6. Heart defect or disease _____ _____ ____________________________________
7. Allergies _____ _____ ____________________________________
8. Breathing difficulties _____ _____ ____________________________________
III. ADDITIONAL INFORMATION
What do you expect to gain/accomplish from participating in therapy? What are your goals?
________________________________________________________________________________________________
________________________________________________________________________________________________
Do others react differently toward the problem? ___YES ___NO If yes, please explain:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Do you have concerns about any other aspects of speech therapy? ___YES
___NO
___Articulation ___Cognition ___Expressive Speech
___Swallowing Difficulties ___Fluency ___Receptive Language
___Auditory Processing ___Sensory Integration ___Reading/Writing
___Other:_____________________________________________________________________________
For Child Patient:
What incentives/rewards motivate your child? (e.g. stickers, food, privileges)___________________________________________
_________________________________________________________________________________________________________
What method of discipline do you practice in your home with your child? (e.g. time-out, temporary loss of privileges/toys)
__________________________________________________________________________________________________________
AdditionalComments/Information:______________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Do you have any circumstances that would make it difficult to attend any follow-up appointments? ___YES ___NO
TO THE BEST OF MY KNOWLEDGE, THIS INFORMATION IS CORRECT
_______________________________________ ______________________________________ _________________
Patient’s name/Responsible Party Printed Name Date
4
06/09

Inova Loudoun Pediatric & Adult Rehabilitation Center Service Policies
We would like to take this opportunity to welcome you to Inova Loudoun Pediatric and Adult Rehabilitation. Our
Center’s mission is to provide excellent care to each patient in a timely manner. Our licensed and certified therapists and
our front office staff are committed to providing you the highest quality services. In order for us to deliver care in the
most efficient and effective way, we request your assistance in complying with our policies which we have established to
guarantee you optimal care and progress.
1) Consistent attendance, crucial to progress during your course of treatment, is required.
2) All appointments are scheduled to allow for direct treatment, consultation and documentation. All appointments need to
begin and end on time. Failure to be prompt for an appointment will reduce the amount of time available for treatment
and interfere with treatment progress.
3) Failure to show up for your scheduled appointment and/or a cancellation with less than 24 hours notice will result
in an automatic charge of $50.00 which must be paid prior to resuming services. Cancellation fees cannot be billed
to insurance. Appointments are in HIGH demand and your early cancellation will give another person the
opportunity to have access to timely care. Multiple cancellations (more than 1 in a 3 month period) and/or noshows
(more than 1) will result in “Same Day Scheduling” pending extenuating circumstances to be determined by
your therapist(s). “Same Day Scheduling” refers to when an appointment is requested by the client and scheduled
on the same day it is to take place. Availability of appointments can not be guaranteed.
4) We highly encourage any cancelled/missed appointments to be made up. Should you wish to make- up an appointment,
please call the office for availability.
5) Front desk staff is responsible for cancellations and rescheduling of all appointments. All questions regarding services,
insurance or billing should be directed initially to the front desk staff.
6) When a therapist is unable to keep a scheduled appointment with a client, the service may be provided by another qualified
therapist upon the request of the client/responsible party as scheduling permits.
7) Payments are due at the time service is rendered. All clients are ultimately responsible for the cost of appointments
scheduled and services received. Our Center will submit charges and accept reimbursement from insurance companies
for which we are a provider. Please keep the front office staff informed of any insurance changes. Charges for claims
denied will resort to the client for immediate payment. Please make sure you are aware and keep track of your
insurance benefits.
8) Please give at least (2) weeks notice prior to discontinuing services to ensure that proper discharge planning/education
can be provided by your therapist.
9) Observation(s) of you and or your child’s Evaluation and/or treatment session(s) may take place by another therapist, your
therapist’s supervisor and/or by students in the field or interested in the field.
I have read, discussed, understand and accept the policies as presented here. Upon signing, I agree to comply fully with
these policies.
___________________________________________________________
Client
_______________
Date
___________________________________ __________________________________ _______________
Parent/guardian if client under 18 Clinician Date
(Rev.6/09; Eff 060308)

44035 Riverside Parkway
Suite 500A
Leesburg, VA 20176
Phone: (703) 858-6667
Inova Loudoun Pediatric & Adult Rehabilitation Center Fax: (703) 858-6665
Emergency Information
Name: ________________________________________________________________________
DOB: ___________________________
SSN: ___________________________________
Emergency Contact Numbers:
1) Name: _________________________________ Relationship to Patient____________________
Phone #: (Home) ___________________________(Cell) _________________________________
2) Name: _________________________________ Relationship to Patient____________________
Phone #: (Home) ___________________________(Cell) ________________________________
Medical Diagnosis:
Medical History:
Allergies:
Current Medications/Dosage:
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
______________________________
Primary Care Physician: ____________________________ Phone #: ___________________
Other Relevant Information:
Last Updated: __________
Next Update in 3 months: __________
06/09