Therapy OPS Tongue Thrust Intake Form

Tongue Thrust Intake Form
Please Note: Every question included in this intake is used to adequately prepare for your or your child's evaluation (i.e., select appropriate assessments, prepare the evaluation space, etc). Each question must be answered before your evaluation can begin.
Today's date:*

MonthDayYear
Date
Patient's First and Last Name:*
Patient's Age:*
Patient's Birth Date:*

MonthDayYear
My child is/I am:*
Age of placement: *
"Other" explanation*
Sex*
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Caregiver 1 Name if under 18 years of age:
Caregiver 1 Cell Phone Number

Area CodePhone Number
Caregiver 1 Date of Birth:
Please send me text reminders:*
I would like my reminder:*
Email address for documents:*
Caregiver 2 Name:
Caregiver 2 Cell Phone Number

Area CodePhone Number
Caregiver 2 Email Address:
Caregiver 2 Date of Birth:
FOR MINORS: If caregivers are not present in the session, therapists often check-in before and after the session to hear about any changes at home/school and what we did in therapy. We will ask you to join us in a room for any personal or in-depth updates. For routine check-ins, are you comfortable discussing this in the lobby? If not, we will ask you to join us in a private room. You may change your mind at any time, but please tell your therapist or the front desk.
Who currently lives with the patient?*
How long have you lived here (St. Paul, south Metro, MN)?
What brought you to this area?
Physician/Primary Care Provider (required to obtain a doctors order in order to bill insurance):*
Primary Care Provider Clinic Name (required to obtain a doctors order in order to bill insurance):*
Primary language spoken in the home:*
How did you hear about us:*
Medical Diagnosis:
Allergies (including nasal congestion):
Current Medications:
School/Program of attendance:
Grade:
Does the patient receive Special Education Services?
If, yes, what?

AcademicBehavioralOccupationalSpeechPhysicalSocial SkillsD/APE
Describe your current concerns as it relates to tongue thrust:*
e.g., open bite, teeth have shifted, cannot get braces until fixed, etc
List past evaluations and therapy:
Is the patient currently receiving therapy at this time?*
If yes, what type of therapy and where?
List past and current orthodontic work:
Has there been any reversals in orthodontic work?
Does your culture have a perspective on therapy? If so, tell us more:
Has anyone in your immediate family been diagnosed with tongue thrust?*
Prenatal/Birth History

Prenatal/Birth History

	Yes	No	Unknown
Full term
Feeding difficulties

Additional details for prenatal/birth history (weeks premature, concerns, etc):
Medical History
History of:*

SeizuresHistory of high feversPneumoniaSinusitisWhooping coughCroupTonsillitisChronic coldsEnlarged glandsHeart troublesAsthmaChronic ear infectionsTraumatic Brain InjuryTongue tieTMJ or jaw painOtherNone listed
Explanation of medical history items:
Are immunizations current
Has the patient ever had*

Serious/recurrent illnessesOperationsAccidentsVision problemsHearing difficultiesDental problemsOtherNone listed
Description of above concerns:
Tongue Thrust History

The following questions help us determine if there is a possible cause for the tongue thrust. Please answer all completely

Did the patient have difficulty*

	Yes	No	Unknown
Sucking
Swallowing
Chewing
Changing to solids

Age transitioned from bottles to cup*
Age transitioned from sippy cup to open cup*
When did pacifier use stop and how often was it used?*
History of thumb or finger sucking?*
If yes, when did the sucking stop?
Speech/Language Development
Which sounds, if any, are incorrect?
Do these sounds impact intelligibility?
Does the patient have difficulty following directions
Social Development

Would you describe the patient as having:*

	Yes	No	N/A
Impulsive
Nervous tics/behaviors
Difficulty learning new things
aggressive behavior

Current Status

The following questions help us plan therapy activities and foods/drinks with which to practice swallowing. Please complete each question.
Favorite foods:*
Adverse foods (if any):
List any dietary restrictions:
Insurance Information and Signatures
Insurance Carrier:*
Policy Holder:*
Employer:*
Group Number:*
Policy Number:*
Does the patient have secondary insurance?*
Secondary Insurance Policy Number:*
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to Therapy OPS. I understand that I am financially responsible for any balance. I authorize Therapy OPS or my insurance company to release any information required to process my claims.

I have custody for the above minor and have been granted the right to legally make all health/therapy decisions regarding him/her. Please list others that share custody and are priveledged to health information:
Others than yourself who have custody of the above named minor:
Signature of parent/guardian/self

Clear
Should be Empty:

Tongue Thrust Intake Form

Prenatal/Birth History

Medical History

Tongue Thrust History

Speech/Language Development

Social Development

Current Status

Insurance Information and Signatures