Outpatient Rehabilitation Services Voice Therapy Adult Patient Intake Questionnaire

Transcription

1 Outpatient Rehabilitation Services Voice Therapy Adult Patient Intake Questionnaire Name: Date of Birth: Today s Date: Age: Referring Physician: Primary Dr: Date of onset: Sudden Gradual Reason for referral: Amyotrophic Lateral Sclerosis (ALS) Brain Injury Cancer Multiple Sclerosis (MS) Parkinson s Disease Spinal Cord Injury Stroke Stuttering Voice Other: 1. How would you describe your health today? Excellent Very Good Fair Poor 2. Describe the injury, incident or diagnosis (include time, place, symptoms experienced). 3. What treatment have you received since the onset of difficulties? 4. Diagnostic Tests: CT MRI Xray Swallow Test Endoscopy Neuropsychological Test Other: 5. Do you have any other medical problems? Yes No If yes, please explain: 6. Significant surgical history: 7. Allergies (Drug, Food, Environmental): 8. Current medications and supplements: Page 1 of 5

2 9. What are your specific goals for voice therapy? 10. Have you noticed any memory or cognitive changes? Yes No 11. Are you 65 or older? Yes No 12. Have you had 2 or more falls in the past year? Yes No 13. Have you had any injury from a fall in the past year? Yes No Daily water intake: <2 glasses (16 oz.) 3-4 glasses (17-32 oz) 5-7 glasses (33-56 oz) 8 or more glasses (>57 oz) Vocal Symptoms Hoarseness Breathy voice Chronic cough or excessive throat clearing Vocal strain or fatigue Inability to speak loudly Loss of voice Vocal Activities (circle all that apply) Telephone without headset Telephone with headset Telephone with speakerphone Talking: one to one conversation Talking in noisy settings Talking to groups Yelling or cheering Environmental/Allergy Issues Smoke Allergens Temperature/Barometric pressure changes Chemicals Other: Reduced pitch range or sudden change in overall pitch Sudden or gradual change in overall vocal quality Voice tremor Diplophonic (double-toned) quality Decreased breath support during speech Whispering Imitating Others Throat clearing Coughing Talking during exercising Singing Other Reflux history Yes No Diagnosis: Gastroesophageal reflux disease (GERD) Laryngopharyngeal reflux (LPR) Other Symptoms: Frequency of symptoms: Page 2 of 5

3 Professional voice use (e.g. teacher, singer): Yes No If yes, describe: Right handed Left handed Home/ Social/ Community 1. Home Situation: house apartment condo/townhome 2. Where: Boulder Broomfield Lafayette Louisville Erie Other: 3. Relationship status: single married divorced dating 4. Who do you live with? 5. Children: Yes No Grandchildren: Yes No 6. Pets: 7. Do you feel safe at home? Yes No Education/Occupation 1. Are you currently working or going to school? Yes No Retired On Disability 2. Education : GED high school some college Bachelor s Master s PhD Tech/Vocational 3. What is/was your area of study? 4. Learning Style: Doing Visual Listening Reading/Written handouts 5. What do you do for work? 6. How many hours do you work per week? 7. Did you take any time off from work? Yes No If yes, how long? Why? 8. Do you volunteer? Describe: 9. Hobbies/Interests/Social Life: 10. What do you do for exercise? 11. How often? Physical: decreased balance decreased endurance headaches Jaw pain/tmj nausea pain paralysis swallowing vertigo Page 3 of 5

4 Psychosocial/Emotional: anxiety anger control/temper outbursts change in sex drive depression driving anxiety flashbacks easily upset or angry, cries easily frustration grief and loss issues irritability panic attacks relationship difficulties sleep problems stress 1. Who is part of your support system? 2. How are they helping you? 3. Have you participated in mental health therapy or counseling before? Yes No Sleep: Check the words that describe your sleep No problems Intermittent Awaken fatigued awakening Difficulty falling Insomnia asleep Nightmares Restless sleep Other: 1. Do you take sleep medication? If so, what do you take? _ 2. Do you take naps? Yes No How many per day? 3. Have you been diagnosed with: Sleep Apnea Narcolepsy 4. How many hours of sleep do you usually get? 5. What time do you usually go to bed? What time do you wake up? Appetite: Same no problems No appetite Increased appetite Decreased appetite Forget to eat Gained weight Lost weight Decreased sense of taste or smell Special diet: Other: # of meals/day # of snacks Page 4 of 5

5 Substance Use: # Caffeinated drinks Do you drink alcohol? Yes No If yes: # of alcoholic drinks Per day Weekly Socially Do you smoke tobacco? Nonsmoker Current smoker Former smoker At what age did you quit? For current and former smokers, At what age did you begin smoking? Cigarettes: cigarettes per day; packs per day Pipe: per day Cigar: per day Chewing tobacco: per day; week Do you use any recreational drugs? Yes No How often? Hearing No difficulties Tinnitus/ringing in the ears Sensitivity to noise Decreased hearing acuity Decreased auditory processing Do you wear hearing aids? Yes No Do you wear them consistently? Yes No Do they help you? Yes No Vision Glasses for reading Glasses for vision Contact lenses No difficulties Blurry vision Sensitivity to light Double vision Decreased peripheral vision Headaches with reading Decreased tracking abilities Driving/Transportation Do you have any difficulties with driving? Yes No If yes, please explain: Cultural/Spiritual Concerns Do you have any cultural or spiritual concerns that we should consider during your therapy? Patient Signature Date/Time Thank you! Please turn this questionnaire in to the Outpatient Rehabilitation check in desk during the check in process the day of your evaluation. Page 5 of 5