Microsoft Word - ??????-2.doc

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1 伃 University of South California University of North Texas ~

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6 - (USC University Hospital) Norris (USC Norris Cancer Hospital) 1991 PMV (Passy Muir Valve) 6

7 ( ) / Dilatation

8 3. Modified Barium Swallow MBS Neuromuscular Electronic Stimulus NMES laryngeal manipulation 4. Dilatation Cricopharyngeal muscle Dr. Sinha 8

9 Dr. Sinha The University of North Texas Speech and Hearing Center ( ) 9

10 ( ) ( ) - 10

11 - ( / / ) ( ) ( ) (skilled nursing facility, SNF) 11

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14 - University of North Texas Speech and Hearing Center Adult Speech-Language Evaluation Case History Form Name: Birthdate: Age: Gender: Address: Home Phone: City: State: Zip Next of kin: Phone: Referred by: Relationship Insurance information: Person completing form self other Reason for Evaluation Please describe your communication difficulty (you/your refers to the client) How long have you been experiencing problems with your communication? Please describe how your communication problems are impacting your daily life. 14

15 Have you been treated by a speech pathologist for this problem? No Yes Where? Length of treatment Reason treatment stopped Other treatment (describe) Is your primary care physician aware of your communication problems? Yes No Name of Primary Care Physician Phone: Background Information Please tell us a little about yourself Highest education obtained: Year Are you currently a student? No Yes (Major) Current Employment: Full-time Part-time Retired Not employed Vocation: Employer: Persons authorized to receive medical information about you: Name Relationship Please describe your interests and activities: Health/Medical Information Please describe any medical conditions you believe might be causing your communication problems: 15

16 Do you have a history of any of the following? (Check all that apply): Hearing problems Chronic sinus problems Stroke Frequent laryngitis Brain injury Respiratory problems/copd Neurologic disease Tumors of mouth, neck, throat Brain tumor Head/neck surgery Paralysis or muscle weakness Immune deficiency Coordination problems Learning disabilities Balance problems Depression/Emotional disorder Seizure disorder Other (describe) Chemical dependency Other (describe) Please list all medications you are currently taking Medication Name Dosage Reason prescribed Please describe your tobacco/alcohol habits Tobacco: Do not use Use less often than daily Daily use Alcohol: Do not use Use less often than daily Daily use Do you wear a hearing aid? Yes No Do you wear dentures? Yes No Do you wear glasses? Yes No Please describe specific information you would like to obtain during this evaluation. Please describe any questions you would like answered regarding your communication. Please describe specific ways you would like your communication to improve. 16

CA KPIF 2008 Nov. KFHP/KPIC Application Chinese Prospect

CA KPIF 2008 Nov. KFHP/KPIC Application Chinese Prospect KAISER PERMANENTE 之個人和家庭健康保險申請表 1 20 備註 : 請回答所有問題, 並僅用墨水筆填寫或用打字機打出您應該只有在理解各問題並同意所提供的回答後再簽署本申請表, 即使是經紀人幫助您申請也應如此若您對完成本申