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Patient Information

Please note: This is a lengthy form so please allow yourself 5-10 minutes to complete.

Insurance Information

SPEECH, VOICE OR HEARING HISTORY


Have you ever had speech therapy, voice therapy?

VOICE ABUSE QUESTIONNAIRE

Please rate how frequently you do each of the following behaviors:
How much of each of the following do you have daily:

Select the response for each statement that indicates how frequently you have the same experience:

VHI-10 Instructions: These are statements that many people have used to describe their voices and the effects of their voices on their lives.
RSI Instructions: These are statements that many people have used to describe different "throat" symptoms and the effects on their lives. Within the last MONTH, how did the following problems affect you?

LIST OF ALL MEDICATIONS/HERBALS/SUPPLEMENTS

I take the following prescription medications:

I take the following over-the-counter medications:

I take the following herbals, vitamins/minerals, and dietary/nutritional supplements: