Voice Evaluation. Voice Evaluation Template 1
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1 Voice Evaluation Template 1 Voice Evaluation Name: ID/Medical record number: Date of exam: Referred by: Reason for referral: Medical diagnosis: Date of onset of diagnosis: Other relevant medical history/diagnoses/surgery Medications: Allergies: Pain: Primary languages spoken: Educational history: Occupation: Hearing status: Vision status: Tracheostomy: Mechanical ventilation: Subjective/Patient Report: Observations/Informal Assessment: Vocal Hygiene Daily water intake: <2 glasses (16 oz.); 3-4 glasses (17-32 oz); a--5-7 glasses (33-56 oz); 8 or more glasses (>57 oz) Daily caffeine intake (coffee, tea, colas, others): Daily alcohol servings: 0; 1; 2, 3; >3; Other Smoking history 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 Smoke recreational drugs: per day; week; month
2 Voice Evaluation Template 2 Vocal Activities (describe all that apply) Hrs. per day/comments Telephone without headset Telephone with headset Telephone with speakerphone Talking: one to one conversation Talking in noisy settings Talking to groups Yelling or cheering Whispering Imitating Others Throat clearing Coughing Phonation during exercising Singing Other Environmental Issues (Describe only those that apply) Comments Smoke Chemicals Allergens Temperature changes Reflux history Yes No Diagnosis: Gastroesophageal reflux disease Laryngopharyngeal reflux Other Symptoms: Frequency of symptoms: Management (check all that apply): Behavioral Medication Dose Vocal Performer: Yes No Vocal training type: # of years performing: Singing range: type of music performed: type of accompaniment:
3 Voice Evaluation Template 3 type of amplification used when performing: Performance venues: Amount of practice per week: Warm up/cool down regimen Other: Oral-Motor Assessment [ ] WNL [ ] Notable for Auditory-Perceptual Evaluation of Voice Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) [PDF] CAPE-V Purpose and Applications [PDF] Laryngeal Performance /s/:/z/ Ratio: functional for speech reduced laryngeal function relative to respiration Maximum Phonation Time: adequate for speech reduced unstable tone unstable pitch unstable loudness Comments: Pitch Glide : WNL; pitch breaks; reduced range; tension; cessation of voicing. Comments: Pitch range during speech: Voice onset delay: not present present. Comments Muscle Tension Assessment Tension Observed: None; Jaw; Neck; Shoulders; Face; Lips; Other: Comments
4 Voice Evaluation Template 4 Laryngeal Carriage At rest: neutral carriage; high carriage; low carriage Elevation during connected speech: Elevation during sustained vowel: Tenderness w/palpation/massage: no yes ( right; left; bilateral) Reduced thyrohyoid space at rest: no yes Tongue base tension w/voicing: no yes At rest: no yes Comments: Breath Support At rest Abdominal Thoracic Clavicular Reverse Abdominal Anchored Mixed Comments: Sustained Phonation Abdominal Thoracic Clavicular Reverse Abdominal Anchored Mixed Comments: Conversation Abdominal Thoracic Clavicular Reverse Abdominal Anchored Mixed Comments: Speaks on Residual Air: yes no
5 Voice Evaluation Template 5 Postural Alignment Stance: balanced; slumped; militaristic; weight forward; weight back; right leaning; left leaning; Neck: free and loose; jaw jut; static; Shoulders: Symmetrical; right higher than left; left higher than right; both high; Pelvis: unremarkable; lordosis; knees locked; Comments: Therapeutic Probes Therapeutic techniques attempted and results Shifting tone focus Easy onset Hard glottal onset Easy onset Breath support Postural adjustment Laryngeal manipulation Increase loudness Decrease loudness Increase fundamental frequency Decrease fundamental frequency Other Stimulability and level of cueing Findings No voice impairment (mild, mild-moderate, moderate, moderate-severe, severe) voice impairment characterized by NOMS Voice score (1-7) Impact of Voice Impairment on Functioning: Activity Limitations and Participation Restrictions (check all that apply): Mild Moderate Severe Daily activities Interpersonal interactions Education Employment Community
6 Voice Evaluation Template 6 Prognosis for improvement with treatment good fair poor, based on Recommendations Voice treatment: yes no Frequency: Duration: Other suggested referrals Gastroenterology Neurology Otolaryngology Psychology Pulmonology Other Other recommended procedures: Endoscopy Stroboscopy Other Patient/Caregiver Education Described results of evaluation Patient expressed understanding of evaluation and agreement with goals and treatment plan Patient expressed understanding of evaluation but refused treatment Family/caregivers expressed understanding of evaluation and agreement with goals and treatment plan. Patient demonstrated recommended strategies Family/caregivers demonstrated recommended strategies Patient requires further education on strategies Family/caregivers require further education on strategies Other Treatment Plan Long-Term Goals Short Term Goals
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