FFST Website Patient Information Form

Patient Information
Patient's Name*

First NameLast Name
Patient's Birth Date*

MonthDayYear
Patient's Gender*

MaleFemaleOther
Parent/Guardian Name

First NameLast Name
Relationship To Patient*

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Primary Phone Number*
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Primary Email*
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Who referred you to FFST? (How did you find us?)*
Areas of Concern
Feeding: Infant, Toddler, Child, Neurodivergent Adult

SwallowingLactation ConsultingG/NG/GJ TubeExtreme Picky EatingInfant Feeding IssuesOral MotorFood AversionBottle Feeding/WeaningMealtime AnxietyARFIDIntroducing SolidsTongue-Lip Tie(s)
Speech & Language: Infant, Toddler, Child, Neurodivergent Adult

ArticulationApraxia Of SpeechStutteringLispExpressive LanguageComprehensionCommunication DeviceLate TalkerVoice TherapyAuditory Processing
Social Skills & Executive Functioning: Child 4 yrs +, Neurodivergent Adults

Pragmatic LanguageEmotional DysregulationSocially AwkwardConcussionADD/ADHDFixed MindsetSocial AnxietyAutism SpectrumTime ManagementOrganizationFlexibilityTask InitiationImpulsiveProblem SolvingAttention
Motor & Sensory: Infant, Toddler, Child, Neurodivergent Adult

SittingCrawlingWalkingDraw/ColorHandwriting/DysgraphiaCuttingTying ShoesThrow/Catch BallRiding BikeClumsyBalanceCoordinationAvoid: Tastes, Smell, NoiseSeek: Touch, Movement, Oral InputLight Sensitivity
Myofunctional: Child 4 yrs +, Adults

MalocclusionTongue ThrustTMJ - Jaw PainOrthodontic PlateauSleep ApneaSwallow IssuesOrthodontic RelapseSleep Issues/SnoringAllergiesENT Surgical HistoryChronic Mouth BreathingTongue-Lip Tie(s)
Other

Dyslexia/ReadingSchool Advocacy
Contact Information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Practice*
Physician Name*
Payment Information
Method Of Payment*

InsurancePrivate PayOther
Insurance Provider

Blue Cross Blue Shield (In-Network)CIGNA (In-Network)United Healthcare (In-Network)TRICARE (In-Network)Aetna (Out-of-Network)BaylorScott&White Health (Out-of-Network)Other
Policyholder Employer/Company Name
Insurance: Support Phone Number (Back of Insurance Card)
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Insurance: Member ID
Insurance: Group Number
Insurance: Policy Holder Name

First NameLast Name
Insurance: Policy Holder Birthday

MonthDayYear
Date
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