BAYLOR ALL SAINTS MEDICAL CENTER D. WAYNE TIDWELL VOICE, SPEECH, AND SWALLOWING CENTER NEW PATIENT VOICE QUESTIONNAIRE
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- Wilfrid Clyde Norton
- 5 years ago
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1 Name: Date of Birth: Address: Referring Doctor: Diagnosis: Phone Number: (home) (business) (mobile) What is your goal regarding your problem or condition? Do you have a follow-up appointment scheduled with your referring physician? If so, please list date and time. Do you have any pain today? If yes, on a scale of 0 to 10 with 0 being no pain and 10 being the worst pain, how would you rate your pain? Location of pain History: Occupation: When did your voice problem begin? Did your voice problem start suddenly or gradually? Describe your voice problem in your own words. _ Please check all the following symptoms that apply to you: breathiness voice too loud roughness voice too soft gravelly voice quality whisper only (total loss of harsh voice quality voice) raspy voice quality straining to speak scratchy voice quality vocal fatigue shaky voice throat pain unsteady voice nasality voice breaks noisy breathing pitch breaks excessive throat mucus voice too high foreign body sensation in voice too low or deep throat difficulty speaking loudly heartburn difficulty speaking softly indigestion bitter or metallic taste after waking sudden coughing after lying down chronic throat clearing chronic cough halitosis worse voice when you wake increased or chronic post nasal drip tooth decay chronic bronchitis 1
2 Have you had the same or a similar voice problem in the past? If yes, please explain. Do you feel it takes effort to speak? If yes, please explain when this occurs and how long effort to speak lasts. Has your voice returned to normal at any time since the problem began? If yes, please describe how long and how often normal voice is present. Does the problem worsen the more you talk? Does voice rest help your voice? Is it worse in the morning or in the afternoon/evening? Is your voice worse during certain seasons? Does anything help or hurt your voice? Are there any vocal activities you can no longer do secondary to this voice disorder? Can you be heard over ambient noise? Do others often ask you to repeat? What bothers you most about your voice problem? Do you participate in fewer social activities since your current difficulty began? Has the problem interfered with any of your work activities (paid or volunteer)? Compared to your recent voice problem, how does your voice sound today? (typical, somewhat better, much better, somewhat worse, much worse) Were there any events or conditions which you associate with the onset of your voice problem? (check all that apply and describe below) NONE Increased voice use Emotional stress Vocal abuse (yelling/screaming) Injury (trauma) Describe: Upper respiratory infection (cold/flu) Swallowing difficulty Surgery Other Specify: How often do you experience reflux symptoms (daily, weekly, monthly)? When reflux occurs, how do you treat it? Do you have any pain and/or tension in your jaw, neck, or shoulders? If yes, 2
3 please indicate if this pain or tension is a sharp, stabbing pain, dull muscular ache, or a raw pain (like a sore throat). Have you ever had therapy or surgery for this or any other voice related condition? If yes, please list dates, location, therapists, and results of therapy. Have you had any choking or swallowing problems? If yes, please explain how often, when, and with what food or drink consistencies. Also note if swallowing problems began before or after your voice problem. Do you have pain when swallowing? Have you had any recent surgeries? If yes, please explain. Have you had any recent neck injuries? If yes, please explain. Have you ever worked around any toxic fumes (gas, paint, chemicals)? List current neurological problems (diagnoses and dates). Do you have a known (diagnosed) hearing loss? If yes, do you or have you ever worn hearing aids? Social History: Are you single? married? widowed? Do you live alone? If no, with whom? D o you have children? If yes, please list how many and if you have grandchildren. Please list your education level. General Medical Health: Arthritis Asthma (adult/childhood onset) Bronchitis Blood Sugar (high/low) Diabetes (adult/childhood onset) Headaches Heart Disease High Blood Pressure Kidney/Bladder Disease Liver Disease Lung Disease Joint/Bone Disease Tuberculosis Cancer Thyroid disease Neurologic Disorders Depression Bleeding Problems Stroke GI Disorders (hernia, ulcers, colitis, etc.) Sinus Disease Endocrine Disorder 3
4 Other: Do you have allergies to foods? drugs? environments? For females only: Are you pregnant? Have you gone through menopause? Do you have regular menstrual cycles? If yes, please date of most recent period. Does your voice change during your menstrual cycle? If yes, please describe. Vocal Use: *Please answer the following questions using this scale: 0 = none, 1 = less than average, 2 = average, 3 = more than average. Do you scream (not necessarily in anger, for example, at a sporting event or while working in a noisy environment)? Do you raise your voice (e.g. parenting, calling from room to room, etc.)? Do you talk for long periods of time without a break (teacher, singer)? Are you a talker? Do you clear your throat? Do you cough? Do you sing? If yes, please explain. How often do you use the telephone? Do you do impersonations, character voices or unusual sound effects? Please list any hobbies or activities you enjoy. Vocal Hygiene: What is your current weight? Please list how much of the following you drink in ounces per day. 1 cup/glass = 8 oz. Water Coffee Tea Soda Energy drinks Milk Juice Sports drinks Other (please specify) How often do you drink alcoholic beverages (daily, weekly, rarely, never, etc.)? Amount in ounces: Beer Wine Liquor Are you currently using tobacco products? YES/NO If yes, list type How much (packs/cans/etc.) per day? For how long? Have you used tobacco products in the past? YES/NO If yes, list type How much (packs/cans/etc.) per day? For how long? Date of cessation Are you exposed to secondhand smoke? YES/NO If yes, please explain. 4
5 Do you use products containing menthol? YES/NO If yes, please list. Do you take Vitamin C supplements? YES/NO If yes, please list amount (mg) per day. Do you use recreational drugs? YES/NO If yes, please list type/amount/frequency. Would you like this report sent to anyone other than the referring physician? If so, please ask front desk for an information release form. Patient Signature Date 5
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#102, 506-71 Ave SW Calgary AB T2V 4V4 Ph 587.352.9199 Fax 1.888.501.1724 info@fullcirclecalgary.ca www.fullcirclecalgary.ca Part 1: BASIC INFORMATION HEALTH INFORMATION FORM Name: Date: Address: City:
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This questionnaire is designed to help patients with headaches. No doctors or pharmaceutical companies will profit from this questionnaire. Our only goal is to gather data on patients with headaches to
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