15 W. Dry Creek Circle 6169 S. Balsam Way; Suite 290
Littleton, CO 80120-4427 Littleton, Colorado 80123
Phone: (303) 798-1309 Fax: (303) 798-2319
Ear, Nose & Throat Center
Specialists of the Ear, Nose and Throat / Head and Neck Surgery / Facial Plastic Surgery
Evaluation of Dizziness & Vestibular Disorders
For more information see us at our web site ! http://www.ENT Center.Net
New Patient Voice Questionnaire
This Questionnaire should be filled out by the patient at home and brought to the office so the
doctor can review it during the office visit. Please print a copy to bring with you.
Part I: General Medical Information
1. Name: 2. Date:
3. Age: 4. Sex:
5. Date of Birth: 6. Height:
7. Weight: 8. Race:
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9. What is your occupation? If you have more than one, please list your primary work |
first, secondary work second, etc.
a.
b.
c.
d.
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10. Do you have any medical problems ? If so, please list them below. Please include frequent sore throats, allergy, asthma, hormone, acid reflux (hiatal hernia), loss of hearing, and emotional problems. |
a.
b.
c.
d.
e.
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11. Please list any surgeries or examinations under anesthesia you have undergone, |
along with approximate dates.
a. Date:
b. Date:
c. Date:
d. Date:
C. Date:
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12. Do you take any of the following medicines ? If yes, specify name and dose. |
a. Aspirin or Arthritis yes no name: dose:
b. Allergy Meds yes no name: dose:
c. Birth Control Pills yes no name: dose:
d. Other Hormone yes no name: dose:
e. Anti-depressant yes no name: dose:
f. 'Tranquilizer yes no name: dose:
g. Diuretic (Water Pill) yes no name: dose:
h. Antacids yes no name: dose:
i. Other name: dose:
name: dose:
13. Please list allergies to medicines, if any:
14. a. How many packs of cigarettes do you smoke each day ?
b. For how many years ?
15. On average, how many cups of fluid do you drink in a day ?
16. How many of these are caffeinated? (coffee,tea, cola) ?
17. How much alcohol do you drink?
Part II: Onset and Description of the Problem
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18. Please summarize your voice problem as briefly as possible: |
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19. How long ago did your voice problem start? |
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20. How did the problem start? Circle the appropriate answer below: |
a. Gradually b. Intermittently (on and off) c. Suddenly
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21. Was there an obvious cause? |
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22. On the scale below, where 1 is none, 4 is moderate, and 7 is extensive, please indicate |
the degree of trouble you are having with the following symptoms.
None Moderate Extensive
a. Hoarseness 1 2 3 4 5 6 7
b. Breathiness 1 2 3 4 5 6 7
c. Harshness 1 2 3 4 5 6 7
d. Too much effort to speak 1 2 3 4 5 6 7
e. Voice Fatigue (aching or tightness
in the front of neck, choking sense
tion, etc., with or without voice
change) 1 2 3 4 5 6 7
f. Tendency to "run out of air" when
speaking 1 2 3 4 5 6 7
g. Reduced endurance (amount of
time you can talk or sing before be
coming husky or hoarse) 1 2 3 4 5 6 7
h. Chronic sore throat, especially in
a.m. 1 2 3 4 5 6 7
i. Sensation of squeezing or of a lump
in the throat 1 2 3 4 5 6 7
j. Burning sensation with voice use 1 2 3 4 5 6 7
k. Frequent need to clear throat 1 2 3 4 5 6 7
1. Chronic, irritative cough 1 2 3 4 5 6 7
m. Heartburn or acid belching 1 2 3 4 5 6 7
n. Food sticking in throat 1 2 3 4 5 6 7
0. Coughing during eating 1 2 3 4 5 6 7
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(If you are not a singer, please skip from here to the next question; if you are a singer, |
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please continue with this question) |
p. Too much effort to sing 1 2 3 4 5 6 7
q. Loss of high notes 1 2 3 4 5 6 7
r. Variability, undependability of
voice for performing 1 2 3 4 5 6 7
s. Problem with delayed "onsets" es
pecially during soft singing and
staccato 1 2 3 4 5 6 7
t. Loss of flexibility 1 2 3 4 5 6 7
u. Reduction of overall usable range 1 2 3 4 5 6 7
v. Tendency to "run out of air" when
singing 1 2 3 4 5 6 7
w. Loss of loudness 1 2 3 4 5 6 7
23. In your opinion are your symptoms: (Circle the best answer)
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a. Improving b. Stable c. Worsening |
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24. Circle the number on the scale below which corresponds to how severe your problem seems to you, where 1 is a mild problem, 4 is a moderate problem, and 7 is a severe problem. |
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1 2 3 4 5 6 7 |
25. In your opinion, what part did the following factors play in causing your voice problem? (1 is none, 4 is moderate, and 7 is extensive). Please circle the appropriate number to the right of each factor.
Mild Moderate Extensive
a. Smoking 1 2 3 4 5 6 7
b. Alcohol 1 2 3 4 5 6 7
c. Upper respiratory infection 1 2 3 4 5 6 7
d. Allergies 1 2 3 4 5 6 7
e. Surgery on vocal folds 1 2 3 4 5 6 7
f. Breathing tube for general anesthesia 1 2 3 4 5 6 7
g. Injury to neck 1 2 3 4 5 6 7
h. Deterioration of voice with menses 1 2 3 4 5 6 7
i. Birth control pill or other hormones 1 2 3 4 5 6 7
j. Other medication 1 2 3 4 5 6 7
k. Not enough fluid intake 1 2 3 4 5 6 7
l. Frankly injurious vocal habits such
as yelling at athletic events 1 2 3 4 5 6 7
m. Work-related vocal demands 1 2 3 4 5 6 7
n. Poor singing technique 1 2 3 4 5 6 7
0. Poor speaking technique 1 2 3 4 5 6 7
p. Too much singing, even though
you were singing correctly 1 2 3 4 5 6 7
q. Too much speaking, even though
you were speaking correctly 1 2 3 4 5 6 7
r. Emotional factors 1 2 3 4 5 6 7
s. Other (explain) 1 2 3 4 5 6 7
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26. Indicate on the scale below the extent to which your voice varies on a day to day basis, where 1 is none at all, 4 is moderately, and 7 is an extreme amount |
1 2 3 4 5 6 7
27. Please indicate on the numerical scale the amount of vocal difficulty you have with the following situations, where 1 is none, 4 is moderate, and 7 is a severe amount of difficulty.
None Moderate Severe
a. Quiet conversation 1 2 3 4 5 6 7
b. Talking over noise, yelling 1 2 3 4 5 6 7
c. Teaching, supervising 1 2 3 4 5 6 7
d. Public speaking, singing, acting 1 2 3 4 5 6 7
e. Telephone conversation 1 2 3 4 5 6 7
f. Other:
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28. On a scale of 1 to 7 where 1 is of no importance, 4 is of moderate importance, and 7 is |
extremely important, please rate the following:
a. Use of voice for work 1 2 3 4 5 6 7
b. Use of voice for public performance 1 2 3 4 5 6 7
c. use of voice for socializing 1 2 3 4 5 6 7
(1. use of voice for home an(family 1 2 3 4 5 6 . 7
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29. On a scale of 1 to 7, where 1 is no problem, 4 is a moderate problem, and 5 is a severe |
problem, please rate the following:
a. Controlling your pitch 1 2 3 4 5 6 7
b. Controlling your loudness 1 2 3 4 5 6 7
c. Controlling your voice quality 1 2 3 4 5 6 7
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30. What is/are the reason(s) you are seeking help with your voice? Please rank the |
choices below from 1 (main reason) to S (last reason).
a. Fear that something serious is wrong (like cancer)
b. Discomfort or pain
c. Displeasure with the sound of your voice
(1. Comments or reactions of other people to your voice
e. Inability to get your voice to do or sound like it should.
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31. Please circle the number on the scale below which best corresponds to your general degree of talkativeness, where 1 denotes a very quiet person, 4 an averagely talkative person, and 7 a very talkative person. |
1 2 3 4 5 6 7
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32. Please indicate on the scale below what you believe to be the average loudness of your speaking voice, where 1 is very soft, 4 is moderately loud, and 7 is extremely loud. |
1 2 3 4 5 6 7
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33. Please circle the number below which you believe best indicates the usual pitch of your speaking voice, where 1 is extremely low, 4 is of average pitch, and 7 is extremely high. |
1 2 3 4 5 6 7
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34. Please indicate on the scale below what you believe to be the overall quality of your speaking voice, where 1 is very poor, 4 is average, and 7 is excellent. |
1 2 3 4 5 6 7
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35. Have you been examined previously by an ENT doctor for this voice problem? yes no |
(If yes) Name: Approx. Date:
Diagnosis:
Name: Approx. Date:
Diagnosis:
36. Have you worked with a speech (voice) therapist? yes no
(If yes) Name: Approx. Date:
Approx. number of sessions:
Name: Approx. Date:
Approx. number of sessions:
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37. If you have had voice therapy, please indicate on the numerical scale below the effect it seemed to have on your symptoms, where 1 is much worse, 4 is no change, and 7 is much improved. |
1 2 3 4 5 6 7
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38. Have you ever had vocal fold surgery: yes no |
(If no, skip to question 40; if yes, continue with question 38) 39. If you have, what was it for?
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40. Please indicate on the scale below the result of this vocal fold surgery, where 1 is marked worsening of your voice, 4 is no change, and 7 is marked improvement of your voice. |
1 2 3 4 5 6 7
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41. Assuming there is a good plan for remediation available for you, how motivated are you to "do what it takes" to improve your voice? Circle the appropriate number on the scale below, where 1 is not motivated, 4 is moderately motivated, and 7 is very motivated. |
1 2 3 4 5 6 7
42. Who else in your family (if anyone) has, or has had, voice problems?
Relationship: Type of disorder:
Relationship: Type of disorder:
Relationship: Type of disorder:
Part III: For Singers/Actors/Professional Voice Users
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43. How many years have you been performing? |
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44. Have you studied with voice/speech teachers? yes no |
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45. How many years, altogether? |
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46. Are you a voice teacher? yes no |
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47. If so, how many years have you taught? |
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48. Do I have permission to confer with your present teacher, as appropriate? yes no |
(( If yes )) Name: Phone:
Address:
49. If you are a singer, what is your voice classification? (Circle One)
soprano mezzo-soprano contralto countertenor
tenor baritone bass-baritone bass
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50. Circle the number below which you believe corresponds best to the "size" of your voice, where 1 is very small, 4 is average, and 7 is "huge." |
1 2 3 4 5 6 7
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51. In what kind(s) of performing situations are you involved? |
a.
b.
c.
d.
For Additional Information press the below link :
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Questionnaire Concerning Voice Problems |
