Fields marked with * are mandatory
       
 
 
*Child's Name
*Date of Birth
  
Medical History (Check all that is applicable)
When did you begin noticing problems with your child's voice?
Can you think of a specific circumstance or event contributing to the onset of the problem?
If so, explain
Is the problem
Does your child complain of the following problems?
  Vocal pain   Vocal fatigue   Difficulty projecting his/her voice   Other
If so, explain
Does your child have a history of any of the following medical conditions?
  Allergies   Asthma   Accident or injury to the neck area
  Hearing loss   Earaches   Sore throats
  Sinus problems   Hormonal issues   Reflux (frequent burping/stomach upset)
  Known vocal disease        
If so, explain
List your child's current medications:
List all surgical procedures with dates:
Is your child currently under a physician's care?
If so, explain
Social History (Check all that apply.)
When is your child's voice worst?
  Sporting activities   Choir singing   Solo singing
  Cheerleading   Weight lifting   Throat clearing
  Breath holding   Harsh laughter   Vocal impersonations
  More than 4 hours of voice use per day   Other strenuous use
If so, explain
Does your child yell   At siblings?   On the playground?   Across the house?   Other?
If so, explain
Does your child smoke or live with a smoker?
If so, explain
How many caffeinated beverages does your child drink daily?
How much decaffeinated liquid does your child drink daily?

Word Verification
Type the characters you see in the picture below:


Note : This information is confidential and intended only for use by Speech Pathways, P.C. personnel.
         
   


 
 
   

Site Map      |      Privacy Policy      |      Disclaimer Policy      |      Copyright