*Name	Age	*Date of Birth
Occupation	Height	Weight

When did you begin noticing problems with your voice?

How did your voice problem begin?   ---Select--- Gradual Suddenly

Please explain

Has your voice improved or gotten worse? ---Select--- Yes No

If yes, please explain

What is the matter with your voice?  (Check all that apply.) Hoarseness  Cannot project  Choking or tickling  Breathiness  Pain Lump in the throat  Fatigue Cannot control Cannot control Prolonged warm up time Voice loss Other Please explain

What kind of physical condition are you in? (Check all that is applicable)

Exercise regularly            Exercises sometimes            Exercise rarely

Do you have breathing problems, especially after exercise?   ---Select--- Yes No

If yes, please explain

Do you have cold or allergy symptoms?  ---Select--- Yes No

If yes, please explain

What medications do you use?  (List all medications.)

Do you smoke, work around smoke or live with a smoker?   ---Select--- Yes No

Have you been exposed to environmental irritants?    ---Select--- Yes No   If yes, please explain

Do any foods seem to affect your voice?   ---Select--- Yes No If yes, please explain

Do you have TMJ problems?    ---Select--- Yes No

Do you have morning hoarseness, bad breath, excessive phlegm or heartburn? ---Select--- Yes No   If yes, please explain

Have you noted voice or bodily weakness, tremor, fatigue, or loss of muscle control? If yes, please explain

Are you having any difficulty swallowing? If yes, please explain

Do you have problems with any of the following symptoms?    Weight control   Fatigue  Temperature sensitivity    Menstrual irregularity  Cyclical voice changes  Recent menopause    Other hormonal issues Please explain

Has your voice been injured? ---Select--- Yes No   If yes, please explain

Did you have surgery prior to your voice problem? ---Select--- Yes No   If yes, please explain

List surgical procedures, dates and affect on the voice.

When are you most aware of your voice problem?  (Check all that is applicable)

Speaking   Singing   Speaking & singing    Professional speaking  A.M.  P.M.   High range use    Low range use

When is your voice the worst? ---Select--- A.M P.M

Explain any vocal fluctuations

Where do you use your voice?  (Check all that is applicable)

Noisy rooms   Cars  Airplanes    Sports facilities  Dusty places  Cheerleading    Teaching   Preaching     Choral conducting  Singing  Acting  Aerobics   Weight lifting    Other Please explain

Do you or any blood relatives have a hearing loss?   ---Select--- Yes No   If yes, please explain

Are you under any particular stress or therapy?  ---Select--- Yes No   If yes, please explain

Do you do any of these?  (Check all that is applicable)  Throat clearing     Coughing      Loud singing   Sound imitations  Excessive talking     Loud talking    Laughing   Impersonations How many of the following beverages do you drink daily? Caffeinated  ---None--- 1-2 3-5 >5 Alcoholic  ---None--- 1-2 3-5 >5 Decaffeinated (includes water) ---None--- 1-2 3-5 >5 How much time do you use your voice per day?  2 to 4 hours    5 to 7 hours  > 8 hours

Additional Comments:

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