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Referred by
________________________ Primary Care physician
________________________ Ear, Nose & Throat
________________________ Speech Therapist
________________________ Voice teacher
When did your voice problem start?
Was the onset sudden? ___ Yes, ___ No
Do you know what caused it? ___ Yes, ___ No
If so, what?
Please summarize your voice problem briefly.
What does your voice do that it should or what does it do that it shouldn’t?
- hoarse, harsh
- lose completely
- lose upper voice
- effortful
- onset delay
- poor endurance
- varies alot
- worse in am
- clear throat often
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- fades with use
- unsteady/wavers/shakes
- chokes off
- drops to a whisper
- can’t yell
- can’t be heard in noise
- painful
- phone a problem
- too low or high
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Swallowing
- painful
- solids a problem
- liquids a problem
- old food comes back up
- lump in throat sensation
Previous treatments
Occupation?
Voice
If you sing, what is your range?
- Soprano
- Mezzo soprano
- Contralto
- Countertenor
- Tenor
- Baritone
- Bass
Have you had training? ___ Yes ___ No ___ Years Smoking History
___Yes ___ previously ___ Never
___ Quit: When? _______
___ Cigarettes: I smoked about ____ packs/day for ____ years
___ marijuana
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Fluids
Water: ___ glasses/day
Caffeine consumption ___ cups/cans/glasses per day (include coffee, tea, colas)
Alcohol: ___ glasses or cans/day week month year ___ quit
Reflux symptoms
- Voice worse in the AM
- Frequently clear throat
- Bad breath/taste in AM
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- Heartburn/hiatal hernia
- Under stress
- Use antacids
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Operations: ___None
- Tonsillectomy
- Neck/Spine Surgery
- Thyroid Surgery
- Heart Surgery
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- Lung Surgery
- Nose or sinus surgery
- Voice box surgery
- Other - please list:
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Medications: ___ None
please list:
Medication ALLERGIES: ___ None
- Aspirin
- Erythromycin
- Sulfa
- Keflex, Ceclor, Ceftin
- Iodine
- Adhesive tape
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- Codeine
- Tetracycline
- Penicillin
- Novocaine
- X-Ray dyes
- Other:
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Do you have problems in these areas?
- Lungs (asthma, emphysema)
- Heart
- Stomach, bowels
- Bladder, kidneys
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- Strokes
- Diabetes or thyroid
- Tremors or unsteadiness
- weakness of arms/legs
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Please use the following scales to rate your problems.
How severe does your problem seem to you?
| mild
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moderate |
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severe
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| 1 | 2 | 3 | 4 | 5 | 6 | 7
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By nature, how talkative are you in recent years?
| quiet/shy
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average |
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very talkative
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| 1 | 2 | 3 | 4 | 5 | 6 | 7
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By nature, how loud spoken do you tend to be?
| nearly a whisper
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average |
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very loud
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| 1 | 2 | 3 | 4 | 5 | 6 | 7
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How much talking does your job or lifestyle require?
| almost none
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average |
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constant
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| 1 | 2 | 3 | 4 | 5 | 6 | 7
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