Patient's Name: *
Patient's Date of Birth: *
Gender: *
Home Address: (please include city, state & zip): *
Email *
Home Phone:
Cell Phone: *
Occupation or School: *
Grade:
Marital Status:
Spouse's Name:
Number of Children:
Referred By: (If referred by a physician or another speech pathologist, please give address and phone number) *
Primary Care Physician (including address & phone) *
Person to contact in case of emergency: *
Relationship to patient *
Phone *
Primary Insurance Company *
Address
Phone
Effective Date
Subscriber Name
Subscriber Birth Date
Member ID # *
Secondary Insurance Company
Address
Phone
Effective Date
Subscriber Name
Subscriber Birth Date
Member ID #
Describe your speech, voice, breathing, swallowing, and/or hearing problem: *
When was this problem first noticed? Was there a triggering event or illness at that time? *
Has the problem become better or worse? Describe any changes. *
Describe how you use your speaking voice, and, if applicable, your singing voice, and in what quantity, both professionally and personally: *
Describe the severity of the problem. Does the severity vary? (e.g. morning vs. evening, with continued vocal use, etc.) *
If you are experiencing vocal cord dysfunction (also known as irritable larynx syndrome or paradoxical vocal fold motion disorder), what triggers your coughing episodes, throat spasms, or breathing issues? *
What do you think caused the problem? *
What has been done about the problem? What sort of treatment has been attempted? *
DATE:
THERAPIST:
ADDRESS:
LENGTH OF THERAPY:
What were the results of the therapy?
Do other members of the family have a speech, voice or hearing problem? *
Describe any pertinent or related medical or psychological factors (medical conditions, special evaluations, diseases, hospitalizations, counseling, treatment). Include hearing problems, allergies, digestive problems, stress-related difficulties, etc. *
Yelling or screaming * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Speaking loudly * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Shouting across a distance * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Speaking/singing over loud background noise, music, TV, etc. * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Clearing throat * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Coughing * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Vocal imitations/sound effects (i.e., trying to sound like someone or something you're not) * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Heavy lifting * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Being in a dry/dusty/fumy environment * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Not drinking enough water * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Smoking * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments: (If past smoker please indicate when you quit)
Going into smoke-filled areas * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Using a belting/screaming singing style * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Use of over-drying medications, such as antihistamines * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Whispering * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Shouting at sporting events * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Excessive laughing * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Excessive crying * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Consuming caffeinated coffee, tea, soda * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Consuming alcoholic beverages * Please Select 0 = Never 1 = Sometimes 2 = Often 3 = Very Frequently
Comments:
Water (oz.) *
Caffeine - coffee, tea, iced tea, cola (oz.) *
Alcohol (drinks/day) *
My voice makes it difficult for people to hear me. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
People have difficulty understanding me in a noisy room. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
My voice difficulties restrict personal and social life. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
I feel left out of conversations because of my voice. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
My voice problem causes me to lose income. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
I feel as though I have to strain to produce voice. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
The clarity of my voice is unpredictable. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
My voice problem upsets me. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
My voice makes me feel handicapped. * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
People ask, "What's wrong with your voice?" * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Hoarseness or a problem with your voice * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Clearing your throat * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Excess throat mucus * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Difficulty swallowing food, liquids or pills * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Coughing after eating or after lying down * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Breathing difficulties or choking episodes * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Troublesome or annoying cough * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Sensations of something sticking in your throat or a lump in your throat * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Heartburn, chest pain, indigestion, or stomach acid coming up * Please Select 0=Never 1=Almost Never 2=Sometimes 3=Almost Always 4=Always
Rate the overall severity of your voice problem: * Please Select Mild Mild-Moderate Moderate Moderate-Severe Severe
Name of Medication / Dosage / Frequency / How Administered *
Name of Medication / Dosage / Frequency / How Administered *
Name of Medication / Dosage / Frequency / How Administered *
Additional comments regarding my medications:
