Speak Up Speech Oregon | Ashley Johnson | Case History Questionnaire

Date*

Patient Name*

Date Of Birth / Age*

Patient Gender*

Female
Male

Parents Names*

Mother's Birthday*

Father's Birthday

Parent's Cell Number*

Email*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

PHYSICIAN

Primary Care Physician*

Who Referred?*

PRIMARY INSURANCE

Insurance Company Name*

Insurance Company Phone Number*

Insurance ID Number*

Insurance Group Number*

Subscriber's Name*

Subscriber's Date of Birth*

SECONDARY INSURANCE

Check One*

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Yes

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Insurance Company Phone Number*

Insurance ID Number*

Insurance Group Number*

Subscriber's Name*

Subscriber's Date Of Birth*

FOR OFFICE USE ONLY

FEEDING

R13.11 (Dysphagia, Oral Phase)
R13.10 (Dysphagia, Unspecified)

AUTISM

F84.0 (Autistic Disorder)
F84.5 (Asperger's Syndrom)

CONGENITAL/CHROMOSOMAL

Q90.9 (Downs Syndrome)
Q93.81 (Velo Cardio Facial Sundrome)
Q35.9 (Cleft Palate)
G80.9 (Cerebral Palsy, unspecified)

HEARING

H91.93 (Bilateral hearing loss)
H91.91 (Unspecified, HL RT
H91.92 (Unspecified, HL LT

ORALFACIAL MYOFUNCTIONAL

K14.8 (Other disease of tongue)
M26.24 (Reverse articulation of dental arch)
M26.50 (Dentofacial abnormality, unspecified)
Q38.1 (Ankyloglossia)
R68.2 (Dry mouth)
R06.5 (Mouth breather)
M26.62 (TMJ Pain)

LANGUAGE

F80.1 (Expressive)
F80.2 (Mixed Expressive/Receptive)
H93.25 (Central Auditory Processing Disorder)

ARTICULATION

F80.4 (Speech to Hearing)
R48.2 (Apraxia)
F80.0 (Phonological)
F80.81 (Stuttering)
F80.89 (Other develop. Disorder SP/Lang.)
R47.81 (Slurred Speech)
R47.89 (Other Speech Disturbance, NEC)
J38.00 (Paralysis Vocal Cord & Larynx, Unsp.)

VOICE

R49.0 (Dysphonia)
R47.1 (Dysarthria)
R47.02 (Dysphagia)

Phone

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Intake Form

PHYSICIAN

PRIMARY INSURANCE

SECONDARY INSURANCE

FOR OFFICE USE ONLY