SPEECH PATHOLOGY
NEW PATIENT INTAKE FORM
Client & Contact Details
Patient first name
Patient surname
Date of birth
Age
Home phone
Mobile phone
Email Address
Home address
Mailing Address (if different)
Parent / Carer Completing this form (if applicable)
Phone
Relationship to Patient
Parent
Guardian
Carer
Other Family Member
Support Co-ordinator
Self
Other
Information on relationship to patient
Funding & Insurance Details
Health Fund (if you do not have private health, please write uninsured)
NDIS
Yes
Self Managed
Plan Managed
NDIA Managed (this practice does not currently see NDIA managed clients)
No
Plan Management Company Details (if NDIS)
Please include the following information: Company Name, Phone Number, Email
Support Co-Ordinator Details (if NDIS)
Please include the following information: Name, Phone Number, Email
Education / Employment
School / Year Level / Occupation
Reason for Referral / Main Concerns
Reason for Referral / Main Concerns
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Reading / Writing (Child & Adult Literacy)
Eating / Swallowing
Speech (clarity, stuttering, voice)
Language (understanding or use/expression)
Communication / Social Skills
Enter additional information below
Additional Information
Please describe the problem: When did it begin? Has the problem changed since first noticed? Is the problem consistent or does it vary? How do you react or respond to the problem, Does it bother you and what do you do about it?
Where else have you been for the problem?
What did they suggest? Did it help?
How have you tried to help the problem?
Why did you decide to come for an evaluation?
Medical & Developmental History
Medical Conditions or Diagnoses
Surgeries, Hospitalisations, or Significant illnesses
Hearing
Normal
Concerns
If concerns please provide information below
Vision
Normal
Concerns
Please provide additional information below
Additional information on hearing and/or vision
Medications
Allergies
Pregnancy & Birth History
Developmental Milestones
Within Normal Limits
Delayed
Please provide additional information if milestones were delayed below
Movement and Communication Milestones
e.g. Crawl 8mths, Walk 14mths, Talk 14mths, 2 Words around 2yrs
Any learning difficulties or additional support required
Yes
No
Details of supports
Language/s spoken at home
Interests / Strengths
Feeding/Eating and Oral Habits
Feeding/Eating/Swallowing Difficulties
Yes
No
Feeding difficulties (past or present)
difficulties with chewing steak, difficulties with managing saliva, difficulties with mixed consistencies
Current Diet - Foods
Regular / Easy to Chew
Soft & Bite Sized
Minced & Moist
Pureed
Liquidised
Current Diet - Drinks
Thin / regular
Slightly thick
Mildly thick
Moderately thick
Extremely thick
Cup Choice
Open Cup
Sippy Cup
Nosy Cup
Bottle
Other Adapted cup/bottle
Infant Feeding
Breastfed
Bottle fed
Mixed
Thumb / Finger Sucking
Yes
No
Currently
Thumb / Finger sucking until
Dummy Use
Yes
No
Currently
Dummy use until
Other Oral Habits
Mouth Breathing
Snoring / Sleep difficulties
Teeth Grinding
TMJ Pain or dysfunction
Nail Biting or other sucking habits
Additional Information (if required)
Please provide any additional information that you feel will assist your speech pathologist
Consent & Privacy Acknowledgment
I consent to the use of AI medical scribe. We utilise a note taking tool called Heidi to accurately and effectively capture the details of our discussions and the outcome of our appointments. Heidi ensures that we can focus more on our conversations and less on manual note taking, enhancing the quality of care that you receive,
Your consent is crucial for us to use this technology. Please understand that your information will be handled with the utmost care, and Heidi's use is aimed solely at improving your healthcare experience.
I confirm that above information I have provided is true, complete and accurate. I understand that the information collected in this form is confidential and used solely for the purpose of providing speech pathology assessment and therapy.
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Signature (Client / Parent / Guardian)
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Date
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