adult hearing case history form - University of Central Florida
adult hearing case history form - University of Central Florida
adult hearing case history form - University of Central Florida
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Communication Disorders Clinic<br />
ADULT HEARING CASE HISTORY FORM<br />
Today’s Date _______<br />
Referred By: ______________________<br />
Name _______________________ Age _____ Date <strong>of</strong> Birth ____________<br />
Address ______________________<br />
Home Phone __________________<br />
City _________ State _____ Zip _______<br />
Cell/Work Phone ___________________<br />
Occupation _____________________ Email: _______________________<br />
1. Have you ever had your <strong>hearing</strong> tested □ yes □ no<br />
If yes, when __________ What were the results _______________________<br />
2. Have you seen a physician about your <strong>hearing</strong> in the past year □ yes □ no<br />
3. Do you hear better in one ear than the other □ yes □ no<br />
If so, which ear is better R L<br />
4. When did you first notice a problem with your <strong>hearing</strong> _______________________<br />
5. Does your <strong>hearing</strong> seem to fluctuate □ yes □ no<br />
6. Are you currently or have you ever been exposed to gunfire, loud machinery, or other<br />
damaging noises □ yes □ no<br />
7. Does anyone in your family have <strong>hearing</strong> loss □ yes □ no<br />
8. Do you ever have ringing or buzzing in your ears □ yes □ no<br />
If so, which ear R L Both<br />
If so, constant ringing or intermittent ringing (Circle one)<br />
9. Have you ever noticed drainage from your ears □ yes □ no<br />
10. Have you ever experienced severe dizziness, loss <strong>of</strong> balance, or spinning sensation<br />
□ yes □ no<br />
11. List any medication you take on a regular basis, including aspirin or herbal supplements.<br />
_____________________________________________________<br />
12. Additional comments about your specific <strong>hearing</strong> situation.<br />
______________________________________________________________________________
COMMUNICATION DISORDERS CLINIC<br />
AUTHORIZATION TO VIDEO TAPE, AUDIO TAPE, PHOTOGRAPH<br />
AND/OR OBSERVE<br />
The <strong>University</strong> <strong>of</strong> <strong>Central</strong> <strong>Florida</strong>’s Communication Disorders Program, in addition to<br />
providing services to the <strong>Central</strong> <strong>Florida</strong> community, functions as a training clinic for<br />
graduate students in the Communication Disorders Program. The <strong>Florida</strong> Alliance for<br />
Assistive Services and Technology (FAAST) also provides similar training and<br />
supervision in conjunction with the <strong>University</strong> Communication Disorders program.<br />
Because <strong>of</strong> this, you may encounter certain situations in the clinic that you might not be<br />
exposed to in another treatment setting.<br />
In order for the student clinician to receive thorough supervision, it may be necessary for<br />
the clinician to tape (Audiotape and Videotape) the sessions. In addition, there is a oneway<br />
mirror in each therapy room, and an observation room adjoining. From time to time,<br />
the student clinician’s session may be observed by the supervisor or by other student<br />
clinicians. At times, video and audio tape(s) may be used for educational purposes.<br />
A fully qualified pr<strong>of</strong>essional supervises each client’s program at the Clinic. Graduate<br />
Students may be assigned to work with certain clients. A qualified faculty member,<br />
however, will be responsible for the pr<strong>of</strong>essional services. This pr<strong>of</strong>essional will<br />
supervise, counsel and direct the clinical activities.<br />
In hereby authorize clinical personnel from the [ ] Communication Disorders Clinic<br />
and/or [ ] FAAST to video tape, audio tape, photograph, and/or observe clinical sessions<br />
for<br />
.<br />
(Client’s name)<br />
Date<br />
Signature <strong>of</strong> Client<br />
Signature <strong>of</strong> Parent/Guardian
COMMUNICATION DISORDERS CLINIC<br />
PERMISSION TO OBTAIN INFORMATION<br />
I herby grant the Communication Disorders Clinic <strong>of</strong> the <strong>University</strong> <strong>of</strong> <strong>Central</strong> <strong>Florida</strong><br />
and <strong>Florida</strong> Alliance for Assistive Services and Technology (FAAST) to request<br />
in<strong>form</strong>ation from the records <strong>of</strong>:<br />
Client’s name: ____________________________________<br />
DOB: ___________________________________________<br />
Agency:<br />
Name: Address: Phone<br />
Number:<br />
1._____________________________________________________________________<br />
______________________________________________________________________<br />
2.______________________________________________________________________<br />
________________________________________________________________________<br />
3.______________________________________________________________________<br />
________________________________________________________________________<br />
4.______________________________________________________________________<br />
________________________________________________________________________<br />
_________________________<br />
Date<br />
_______________________________<br />
Signature <strong>of</strong> Client<br />
_______________________________<br />
Signature <strong>of</strong> Parent/Guardian
COMMUNICATION DISORDERS CLINIC<br />
PERMISSION TO RELEASE INFORMATION<br />
I hereby grant the Communication Disorders Clinic <strong>of</strong> the <strong>University</strong> <strong>of</strong> <strong>Central</strong> <strong>Florida</strong><br />
permission to release in<strong>form</strong>ation from the records <strong>of</strong><br />
to the agencies listed below.<br />
(Client’s name)<br />
Send to:<br />
FAAST, <strong>Florida</strong> Alliance for Assistive Services and Technology<br />
325 John Knox Road, Building 400, Suite 402 · Tallahassee, <strong>Florida</strong> 32303<br />
Solely for the purposes <strong>of</strong> evaluating the services provided by the FAAST Regional<br />
Demonstration Center<br />
(Parent/Guardian initial here)<br />
Send to:<br />
Name: Address: Phone Number:<br />
________<br />
__________________________________________________________________<br />
Date<br />
Signature <strong>of</strong> Client<br />
Signature <strong>of</strong> Parent/Guardian<br />
PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT,<br />
PAYMENT OR HEALTHCARE OPERATIONS
I understand that as part <strong>of</strong> my healthcare, this organization originates and maintains health records<br />
describing my health <strong>history</strong>, symptoms, examination and test results, diagnoses, treatment and any plans<br />
for future care or treatment. I understand that this in<strong>form</strong>ation serves as:<br />
• A basis for planning my care and treatment<br />
• A means <strong>of</strong> communication among the many health pr<strong>of</strong>essional who contribute to my care<br />
• A source <strong>of</strong> in<strong>form</strong>ation for applying my diagnosis and surgical in<strong>form</strong>ation to my bill<br />
• A means by which a third-party payer can verify that services billed were actually provided<br />
• And a tool for routine healthcare operations such as assessing quality and reviewing the<br />
competence <strong>of</strong> healthcare pr<strong>of</strong>essionals<br />
I understand and have been provided with a Notice <strong>of</strong> In<strong>form</strong>ation Practices that provides a more complete<br />
description <strong>of</strong> in<strong>form</strong>ation uses and disclosures. I understand that I have the right to review the notice prior<br />
to signing this consent. I understand that the organization reserves the right to change their notice and<br />
practices and prior to implementation will post in<strong>form</strong>ation <strong>of</strong> this change. I understand that I have the<br />
right to request restrictions as to how my health in<strong>form</strong>ation may be used or disclosed to carry out<br />
treatment, payment or healthcare operations and that the organization is not required to agree to the<br />
restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the<br />
organization has already taken action in reliance thereon.<br />
I authorize UCF Communication Disorders Clinic to use an automated telephone system and/or email and<br />
to use my name, address and phone number; the name <strong>of</strong> my scheduled treating physician; and the time <strong>of</strong><br />
my scheduled appointment(s), for the limited purpose <strong>of</strong> contacting me to notify me <strong>of</strong> a pending<br />
appointment or other healthcare-related communication. I also authorize Communication Disorders Clinic<br />
to disclose to third parties who answer my phone limited protected health in<strong>form</strong>ation regarding pending<br />
appointments, and to leave a reminder message on my voicemail system or answering machine.<br />
______________________________________________<br />
Signature <strong>of</strong> Patient or Personal Representative<br />
____________________<br />
Date<br />
______________________________________________<br />
Printed<br />
Name <strong>of</strong> Patient or Personal Representative
COMMUNICATION DISORDERS CLINIC<br />
DRIVING DIRECTIONS<br />
The <strong>University</strong> <strong>of</strong> <strong>Central</strong> <strong>Florida</strong>’s Communication Disorders Clinic is located in the<br />
<strong>Central</strong> <strong>Florida</strong> Research Park in the Research Pavilion, Building 12424, Suite 155.<br />
From Winter Park<br />
Take <strong>University</strong> Boulevard east to Alafaya Trail, then right (south) to Research Parkway.<br />
Turn left (east) at Bank <strong>of</strong> America, entering <strong>Central</strong> <strong>Florida</strong> Research Park. After<br />
proceeding through the first traffic light, the Research Pavilion will be the third building<br />
on the right.<br />
From Orlando<br />
Take Colonial Drive (State Road 50) east to Alafaya Trail. Turn left (north) onto Alafaya<br />
Trail. At the third traffic light (Bank <strong>of</strong> America’s on the corner), turn right (east) on<br />
Research Parkway, entering <strong>Central</strong> <strong>Florida</strong> Research Park. After proceeding through the<br />
first traffic light, the Research Pavilion will be the third building on your right.<br />
From Orlando<br />
Take the East-West Expressway east. Do not exit to the left where there is a sign<br />
indicating that you should go left to UCF but continue on the expressway until you reach<br />
the Alafaya Trail exit. After exiting, turn left (north) on Alafaya Trail. After crossing<br />
Colonial Drive (State Road 50), proceed to the third traffic light (Bank <strong>of</strong> America’s on<br />
the corner), turn right (east) on Research Parkway, entering <strong>Central</strong> <strong>Florida</strong> Research<br />
Park. After proceeding through the first traffic light, the Research Pavilion will be the<br />
third building on your right.<br />
Please feel free to contact the clinic if you are coming from a location that the above<br />
directions do not cover. Our telephone number is (407) 882-0468.<br />
If you would prefer to use Map Quest for directions, our address is 12424 Research<br />
Parkway, Orlando, FL 32826
Communication Disorders Clinic<br />
Service Fees for Evaluation & Treatment<br />
Speech/Language Pathology Evaluations Fee<br />
Speech and Language Evaluation (child) $200.00<br />
Stuttering Evaluation $200.00<br />
Voice Evaluation w/ laryngeal exam $750.00<br />
Voice Evaluation w/ acoustic exam only $200.00<br />
Reading Evaluation (includes oral language exam) 450.00<br />
Speech and Language Evaluation (<strong>adult</strong>) $250.00<br />
Assistive/Augmentative Device Evaluation $750.00<br />
(FAAST)<br />
Audiology Evaluations<br />
Fee<br />
Auditory Processing Evaluation $190.00<br />
Hearing evaluation (basic) $75.00<br />
Hearing evaluation (extended) $120.00<br />
Earmolds/Earplugs<br />
$55.00 and up<br />
Types <strong>of</strong> Therapy Offered<br />
Fee<br />
Fluency/Stuttering *<br />
Aural Rehabilitation *<br />
Auditory Processing *<br />
Aphasia Therapy *<br />
Voice Therapy *<br />
Preschool Speech (Articulation) & Language *<br />
School-Age Speech (Articulation) & Language *<br />
Adult Speech (Articulation) & Language *<br />
Dysarthria *<br />
Lee Silverman Voice Therapy (LSVT) *<br />
Augmentative and Alternative Communication (AAC) *<br />
Reading & Writing *<br />
Accent Reduction *<br />
Traumatic Brain Injury Program *<br />
Intensive Aphasia Program *<br />
Brain Fitness (Dementia Program) *<br />
*Fees for therapy sessions are determined on a sliding scale based on annual income and<br />
number <strong>of</strong> family members. Please visit the fees chart on our website.