Institute for Voice and Swallowing Voice Questionnaire
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- Kenneth McCarthy
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1 Institute for Voice and Swallowing Voice Questionnaire In order to serve you better, please fill out this form in black ink as completely as possible and bring to your scheduled appointment. If you want to return it via , please send to the designated address, but include your initials only and no other identifying information, as per HIPAA rules. Thank you! IDENTIFYING INFORMATION Today s date: Name: Date of Birth: / / Age: Address: Referral Source: Profession: Telephone: HISTORY OF PRESENT VOCAL COMPLAINT: Describe your voice problem: When did you first notice the voice problem? Onset of problem: Sudden Gradual Were any events associated with the onset of your problem? (check all that apply) Increased voice use Swallowing difficulty Vocal abuse (yell/scream) Injury (trauma) Upper respiratory infection (cold/flu) None Other (specify): 1
2 What do you think is the cause of your voice problem? Is the problem getting: Better Worse Same Fluctuates Voice during the day: Better morning afternoon evening Worse morning afternoon evening Please check all that apply to you: Hoarseness Fatigue (voice tires easily) Voice too loud Voice too soft/weak Pitch too high Pitch too low Frequent voice breaks Breathiness Raspiness Losing your voice completely Tremulous voice Nasal voice Frequent whispering Run out of air when speak/sing Frequent throat clearing Heartburn Noisy breathing Neck/Back Pain Hard or frequent coughing Seasonal Problem Bad/acid taste/breath Other (explain) Post-Nasal drip Frequent sore throat Belching Dry mouth or throat Sensation of phlegm in throat Tickling or choking sensation Tightness or tension in throat Something stuck/lump in throat Hard and abusive laughter Straining or effort in speaking Pain in throat while talking Difficulty swallowing Calling kids/pets from a distance Cheerleading or pep club Lecturing Talkative Yelling (sports event, house, kids) Aggressive personality Singing Imitating Voices/Sounds Frequent exercise (grunting, lifting, aerobics) None Previous voice problems? Previous voice therapy? No Yes, describe: No Yes, describe (who, where, how long) Have you tried to do anything on your own to help your voice problem? Home remedies? Successful? Have you had any prior diagnostic tests? If yes, what were the results? Typical voice use: Home: talkative Average Quiet Work/School: Talkative Average Quiet Social: Talkative Average Quiet Phone: Talkative Average Quiet What do you think your level of stress is on a daily basis? Very Low Average Very High 2
3 Medical History Do you have or have you had any problems listed below? Please check all that apply: Heart attack Liver disease Osteoporosis High blood pressure Hepatitis/Jaundice Broken bones Cardiomyopathy Ulcers Neck/Back pain Heart failure Kidney disease/stones Stroke/TIA Pacemaker Kidney failure/dialysis Seizures Defibrillator/AICD Crohn's/Colitis/IBD Black out/dizziness Chest pain/angina Hiatal Hernia Parkinsons/Alzheimers Angioplasty Asthma Multiple Sclerosis Irregular heart beat/ep study Emphysema/COPD ALS (Lou Gehrig's Disease) Previous heart catheterization Pneumonia Meningitis Poor circulation in legs Bronchitis Migraines/Headaches Heart valve disease Sickle cell disease Heart surgery Anemia Excessive bleeding Cancer Radiation therapy Chemotherapy Urinary problems Endocrine disorder Lupus Depression Anxiety Disorder Psychiatric disorder Immunologic Disease Diabetes/Hypoglycemia Glaucoma Cataracts Cortisone/Prednisone last 12 mo. Arthritis Cleft palate Retinopathy Neuropathy Nephropathy Sinus problems/post nasal drip Thyroid problems TMJ Polio Head injury Tubes, lines or drains Trauma Hearing aid(s) Hearing Impairment Neurologic problems (weakness, numbness, clumsiness, tremors/shaking, confusion) Assistive devices (prosthesis, cane, crutches, brace, walker, wheelchair) Pregnant now or within the last three months Other (specify): Details of any problem checked above: Surgical History (check all that apply): Tonsillectomy Oral surgery Thyroid surgery Adenoidectomy Tracheotomy Radiation (Specify): Appendectomy Lung surgery Back/Neck surgery Abdominal surgery Heart surgery Hysterectomy Larynx/Vocal Fold surgery NONE Other (specify): Details of any surgeries checked above: 3
4 Allergies (Medications, food, iodine, latex, tape, novacaine, shellfish, environment) None Known Allergic to: Social History: Substance Usage, Diet (check all that apply): Smoke packs per day for years Quit smoking; date: Alcoholic beverages per day, per week; Type: Diet pills: Name:, Amount:, How long: Caffeine beverages: per day. Type: Cola Coffee Tea Water Intake: glasses/ounces per day Other drugs/substance usage: Any Chemical/Environmental exposure: Special Diet: Family History (similar problems): SINGING HISTORY (If Applicable): Genre of Music: Classical/Opera Jazz Pop R&B Other Voice Category Soprano Mezzo-soprano Tenor Baritone Bass Lowest note: Highest note: Hours per week Singing/Speaking: Do you perform in these situations: Without a microphone Dusty/Smoky Environment? Over Loud Noise Do you warm up before a performance/speech? Y/N How Long? When is your next performance? Do you take Voice Lessons Now? In the Past? For How Long? Who is your Voice Teacher? 4
5 Medication History Name of Patient: DOB: Initial Name of Person Completing Form: Date: Please write all medications taken currently or within the last 6 months that have been discontinued. List all prescriptions, over-the-counter medications, vitamins, supplements, herbal remedies. Use the following notations next to each entry: = CURRENTLY TAKING D/C = DISCONTINUED MEDICATION Dose/Frequency Initial Date COMMENT INITIALS PRINTED, LEGIBLE NAME INITIALS PRINTED, LEGIBLE NAME 5
6 Review of Systems: (Specify Side or Location if Applicable) Ear pain Decreased hearing Nasal obstruction Vision problems Runny nose Itchy nose/face Trouble chewing Trouble swallowing Painful swallow Regurgitation Change in skin/hair Dry skin Hair loss Easily chilled Hypersensitivity to temperature Easy fatigue Excessive sweat Night sweats Weight gain Weight loss Fever Menopause Jaw pain/tension Neck pain/tension Shoulder pain/tension Abdominal pain Pain with breathing Shaking/tremor Falling Vertigo Poor coordination Seizures Insomnia Memory change Headache Aphasia Stuttering Articulation Disorder Chronic cough Trouble breathing Shortness of breath Heartburn/Indigestion/Reflux Constipation/Diarrhea Nausea/Vomit/Diarrhea Chest Pain Palpitations Change in Urination Arthritis Muscle pain Joint Pain Easy Bruising Allergies Itching Rash Height: Weight: Details of those items checked above: Please list any additional information that may be helpful in the diagnosis and treatment of your problem: 6
7 TABLE 1 Reflux Symptom Index (RSI) Within the last MONTH how did the following problems affect you? 0 = No Problem 5 = Severe Problem 1. Hoarseness or a problem with your voice Clearing your throat Excess throat mucous or postnasal drip Difficulty swallowing food, liquids, or pills Coughing after you ate or after lying down Breathing difficulties or choking episodes Troublesome or annoying cough Sensations of something sticking in your throat or a lump in your throat Heartburn, chest pain, indigestion, or stomach acid coming up Voice Handicap Index (VHI-10), Henry Ford Hospital Please circle the response that indicated how frequently you have these experiences: 0 = never 1 = almost never 2 = sometimes 3 = almost always 4 = always My voice makes it difficult for people to hear me People have difficulty understanding me in a noisy room My voice difficulties restrict my personal and social life I feel left out of conversations because of my voice My voice problem causes me to lose income I feel as though I have to strain to produce voice The clarity of my voice is unpredictable My voice problem upsets me My voice makes me feel handicapped People ask What s wrong with your voice?
8 Scripps Voice/Swallowing Center Voice Disorder Assessment The Glottal Closure Index (GCI) is a fourquestion survey that asses the clinical severity of voice disorders. The survey instrument is designed to be used by a physician or vocal specialist in conjunction with other pertinent patient history and physical examination findings. An abnormal GCI (> 2) may be indicative of a significant voice disorder. Please feel free to take and score your GCI below. The Glottal Closure Index A score > may indicate a significant voice disorder Within the last month, how did the following problems affect you? 0 = no problem 5 = severe problem 1. Speaking took extra effort Throat discomfort of pain after using your voice Vocal fatigue Voice cracked or sound different Total 8
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