Get Demographics And History Form - American Speech-language ... - Asha

This guide provides a detailed overview of how to effectively fill out the demographics and history form required by the American Speech-Language-Hearing Association (ASHA). By following these instructions, you can ensure that all necessary information is accurately captured for optimal support and services.

Follow the steps to complete the form with ease.

1. Press the ‘Get Form’ button to obtain the demographics and history form and open it in your preferred digital format.
2. Begin by entering the patient identification or medical record number in the designated field.
3. Fill in the patient's first name, middle name, and last name as indicated.
4. Provide the complete address, including street number, street name, city, state, and zip code.
5. Input the home phone number, cell phone, and any additional contact number, such as work or other, as applicable.
6. Identify an emergency contact by including their name and phone number.
7. Select the marital status by marking the appropriate option as married, single, divorced, or widow/widower.
8. Enter the date of birth and age of the individual.
9. Indicate gender by selecting either male or female.
10. Choose the race/ethnicity, marking one or more options as applicable.
11. Record the facility admission date and the date of the speech-language pathology evaluation.
12. Provide the name of the referring physician or service and include their clinician ID and National Provider Identifier (NPI) number.
13. Identify the primary funding source by selecting the appropriate option from the provided list.
14. Input the HIC number or insurance ID number if applicable, along with the name of the insured individual.
15. Select any applicable medical diagnoses from the list provided, marking primary or secondary as relevant.
16. Enter the onset date of the primary medical diagnosis.
17. Select all relevant communication/swallowing diagnoses from the options listed.
18. Include any other relevant medical history, diagnoses, or surgeries.
19. List any current medications and their dosages.
20. Document any allergies the individual may have.
21. Select the current treatment setting, marking one or more of the applicable options.
22. Indicate the living situation prior to the onset of the medical diagnosis.
23. Provide details regarding the educational background and employment status.
24. Mark whether English is the primary language, and indicate if an interpreter is needed, along with any additional languages spoken.
25. Document cultural or linguistic considerations, if applicable.
26. State the reason for referral by selecting the relevant reason from the options provided.
27. Indicate any problems or changes in related systems, including hearing, vision, or dentition, and provide necessary details.
28. Complete the hand dominance section.
29. Once all fields are completed, review the information for accuracy before saving the changes, downloading, printing, or sharing the form as needed.

Begin filling out the demographics and history form online today!