Location Preference
For which location are you requesting an evaluation?
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Marlton
Swedesboro
Haddonfield
Telehealth
How did you hear about MJ KIDZ
I heard from:
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Facebook
Google
Primary Care
Other Specialist
Friend
Insurance Company
Current Patient
Other
We want to thank our referrals! Please be as specific as possible or put N/A:
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Patient Medical History Form
Patient's Name
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First Name
Last Name
Patient's Date of Birth
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MM
-
DD
YYYY
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Form Completed By:
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First Name
Last Name
Email
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example@example.com
Phone Number
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Area Code
Phone Number
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Diagnostic History
Please list ALL medical diagnoses along with diagnosing provider and their contact information. If there are no known diagnoses, please put N/A in the first cell:
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Diagnosis
Diagnosing Physician
Diagnosing Physician Phone
Approximate Date of Diagnosis
1
2
3
Describe any evaluations and/or therapy you have undergone for communication, swallowing, behavioral, emotional, or other difficulties. Please include the name of the evaluating specialist. If none, mark "N/A."
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For each diagnosis/condition listed above, and for any additional evaluations undergone, please scan or take a clear photo of the patient's evaluations and/or reports from each diagnosing physician/specialist.
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Please upload any additional paperwork that does not fall under any of the categories above (i.e. surgeries, other relevant medical history documentation)
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Areas of Concern
What is your primary reason for seeking Speech-Language Pathology services? Why do you feel that you need cognitive-communicative, speech and language, swallowing, voice or augmentative and alternative communication therapy? Please be as specific as possible.
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General Medical History
Have you ever had any of the following?
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Seizures
Head Injury
Dental/labial/lingual malformation
Cleft palate
Frenotomy
Tonsils/adenoids removed
Oxygen/breathing loss
Asthma
Meningitis
Encephalitis
Chicken Pox
None
Do you have any allergies or sensitivities? If so, please explain.
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Please list any medications you currently take, along with dosage, who prescribed, and why:
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Hearing History
Do you suspect that you have hearing loss?
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Yes
No
Has your hearing ever been tested by an audiologist?
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Yes
No
If so, where were you seen and when?
Do you use hearing aids?
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Yes
No
Do you have a history of multiple and/or frequent ear infections?
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Yes
No
Educational and Family History
Please list your highest level of education and also your work background if applicable.
Are you currently working?
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Yes
No
If "Yes," please provide details below.
Is English the primary language spoken in the home?
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Yes
No
Multiple Languages
If "No", or "Multiple languages," please specify which language(s) are spoken at home.
Additional Information
Please list any additional information about that you feel it is important for us to know.
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Insurance and Payment Information
Would you like to use your insurance or private pay? We do not accept Horizon NJ Health, United Healthcare Community Plan, United Healthcare Commercial Plans, Aetna Better Health, or Medicare/Medicaid Products. If you would like an estimate for services, please click on private pay.
Insurance
Private Pay
Please note that by choosing private pay I cannot and will not be submitting claims to my insurance company directly. Prior to scheduling an initial evaluation, I understand that I will need to receive and sign a Good Faith Estimate for an estimated cost of services.
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Single
Married
Seperated
Divorce
Other
Primary Insurance (Please select)
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Aetna
AmeriHealth Administrators
Amerihealth NJ
Anthem
Blue Cross Blue Shield (Various States)
Cigna
Corsource
Federal Blue Cross Blue Shield
GEHA
Horizon Blue Cross Blue Shield of NJ
Humana
Independence Blue Cross
Independence Personal Choice
Independence Administrators
Keystone
Meritain
Tricare
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ID Number
Group Number
Effective Date
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/
Month
/
Day
Year
Date
Subscriber's Name
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First Name
Last Name
Front of Insurance Card
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Back of Insurance Card
*
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Secondary Insurance (Please select)
*
Aetna
AmeriHealth Administrators
Amerihealth NJ
Anthem
Blue Cross Blue Shield (Various States)
Cigna
Corsource
Federal Blue Cross Blue Shield
GEHA
Horizon Blue Cross Blue Shield of NJ
Humana
Independence Blue Cross
Independence Personal Choice
Independence Administrators
Keystone
Meritain
Tricare
United Health Care Community Plan
Aetna Better Health
Horizon NJ Health
N/A
ID Number
Group Number
Subscriber's Name
First Name
Last Name
Front of Insurance Card
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Back of Insurance Card
Browse Files
Cancel
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Submit
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