Fillable Voice Intake Form Personal Information (University of Washington)

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Voice Intake Form Personal Information (University of Washington)

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UW Speech & Hearing Clinic 206.543.5440
4131 15
th
Ave NE shclinic@uw.edu
Seattle, Washington 98105-6246 https://sphsc.washington.edu/clinic
Voice Intake Form
Personal Information
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Name ____________________________________________________________________________
Birth Date ______________ Gender _______________________ Pronouns __________________
Street Address ____________________________________________________________________
City, State, ZIP _____________________________________________________________________
(this address will be used for reports unless specified otherwise)
Home phone __________________________ Alternate phone. ____________________________
E-mail address _____________________________________________________________________
Occupation. _______________________________________________________________________
Who referred you to the University of Washington Speech and Hearing Clinic?
_________________________________________________________________________________
Medical History
!
Please list any medical diagnoses.
Medical Diagnosis: _______________________________________________________________
When made: _____________________________
By Whom: _____________________________
Medical Diagnosis: _______________________________________________________________
When made: _____________________________
By Whom: _____________________________
Please add a separate sheet for more diagnoses.
Please list any previous and current voice or respiratory problems and/or diagnoses.
Voice/Respiratory Diagnosis: _________________________________________________________
When made: _________________ By Whom: ___________________________________
Voice/Respiratory Diagnosis: _________________________________________________________
When made: _________________ By Whom: ___________________________________
Please add a separate sheet for more diagnoses.
Voice&Intake&Form&
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2!
Have you ever been assessed by an Ear, Nose and Throat specialist (also called an Otolaryngologist)?
No ____ Yes ____
If Yes, when: _______________ Name of specialist: _________________________________
Reason for consultation: _____________________________________________________________
Please check the types of medications that you take regularly
____ antihistamines (Dimetapp, Chlor-Trimeton, Benedryl, Alavert, Claritin, Zyrtec, etc)
____ analgesics (aspirin, ibuprofen, Advil, Motrin, prescription pain relievers, etc)
____ antihypertensives for high blood pressure
____ corticosteroids (cortisone, hydrocortisone, prednisone)
____ gastroenterologic for reflux, heartburn, ulcers, etc (Zantac, Prilosec, Nexium, etc)
____ psychoactive (depression, anxiety, mood stabilizers, sedatives
____ vitamins and supplements
____ others (please list) ____________________________________________________
Do you suffer from reflux (e.g., take antacids, taste stomach acid in mouth, sit up in middle of night,
belch frequently)? No ____ Yes ____
If yes, are you currently taking any medication to treat reflux? No ____ Yes ____
If yes, what is the name of the medication? __________________________________
Was your reflux diagnosed by a medical professional? No ____ Yes ____
Was your reflux self-diagnosed? No ____ Yes ____
Do you smoke? No ____ Yes ____ If yes, how many cigarettes per day? __________________
If you don’t smoke daily, how many cigarettes have you smoked in the past 30 days? ________
Do you smoke marijuana? No ____ Yes ____ If yes, how much per day? __________________
Are you frequently around other people who smoke? No ____ Yes ____
How much water/non-caffeinated beverages (e.g., water, fruit juices, milk, herbal tea, etc.) do you
drink in a day? Estimate the number of glasses per day calculating 8 oz. per glass.
____ 0-3 glasses/day ____ 4-6 glasses/day ____ 7-9 glasses/day ____ >9 glasses/day
Voice&Intake&Form&
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3!
How much coffee/caffeinated beverages (e.g., power/energy drinks, tea, cola, Mountain Dew, coffee)
do you drink in a day? Estimate the number of glasses per day calculating 8 oz. per glass.
____ 0-3 glasses/day ____ 4-6 glasses/day ____ 7-9 glasses/day ____ >9 glasses/day
Which of the following beverages do you drink and how much of each do you drink each day?
____ Drip coffee (8 oz) How many per day? _______
____ Shot of espresso (1 oz shot)
(shots, lattes, cappuccino, Frappuccino, etc) How many per day? _______
____ Coke, Pepsi, other colas (12 oz.) How many per day? _______
____ Black tea (8 oz) How many per day? _______
____ Green tea (8 oz) How many per day? _______
____ Mountain Dew, Mello Yello (12 oz) How many per day? _______
____ Vault (12 oz) How many per day? _______
____ Amp, No Fear, Red Bull, Rockstar How many per day? _______
____ Enviga, Full Throttle, Monster Energy How many per day? _______
How many alcoholic drinks (1 oz hard alcohol, 12 oz beer, 6 oz wine) do you drink in a day?
____ 0-1 drinks/day ____ 2-3 drinks/day ____ >3 drinks/day
Voice Use
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What is the level of your singing/acting career? ____ Professional ____ Amateur ____Other _______
What are your goals in your singing/acting?
____ Singing/acting as a hobby
____ Professional singer/actor
____ Teacher of singing/acting
____ Other ________________________________
Describe your type of daily voice use. Please check all that apply.
____ 1:1 speaking ____ singing ____acting ____ teaching / presenting
____ group discussion ____ shouting ____ screaming ____ other ____________
Other comments ____________________________________________________
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4!
Describe your performing voice use. Please check all that apply.
____ operatic singing ____ musical theater ____ shouting
____ choir singing ____ contemporary theater acting ____ screaming
____ rock singing ____ classical theater acting ____ 1:1 speaking
____ jazz/R&B/gospel singing ____ group discussion ____ teaching
____ voice-over ____ other ___________ ____ other ___________
Other comments ____________________________________________________________
Do you have any pressing voice commitments currently? ____ No ____ Yes
If yes, please check all that apply and briefly describe these commitments.
____ audition ____ practice/rehearsal ____performance ____other
Please describe. _______________________________________________________
Have you ever seen a specialist (e.g., speech-language pathologist; voice coach; singing instructor)
regarding how you use your voice? List all that apply.
If so, by which specialist? ______________________ When/How long?_________
If so, by which specialist? ______________________ When/How long?_________
If so, by which specialist? ______________________ When/How long?_________
How much voice training have you had?
Singing Acting
____ ____ No training (e.g., no training for voice/acting)
____ ____ Minimal amount (e.g., training through experience)
____ ____ Moderate amount (e.g., attendance at some workshops, a few lessons)
____ ____ High amount (e.g., professional voice/acting lessons, workshops)
If applicable, please describe “other” voice training. ______________________________
________________________________________________________________________
Under what conditions do you use your voice?
____ with amplification ____ without amplification ____ in lots of background noise
____ inside ____ outside ____ smoky clubs ____ other ___________
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5!
Amount of voice use per day for singing/acting practice and/or exercises
____ 0-1 hour ____ 2-4 hours ____ >5 hours ____ other ______________
Amount of voice rest per day (waking hours)
____ 0-1 hour ____ 2-4 hours ____ >5 hours ____ other ______________
Are you aware of any problems with your performing voice? ____ No ____Yes
If yes, please describe. _____________________________________________________
Are you aware of any problems with your regular speaking voice? ____ No ____ Yes
If yes, please describe. ____________________________________________________
Continue on next page…
Voice&Intake&Form&
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6!
Different people use their speech in different ways. Think of how you have typically used your speech
over the past year. Choose the category below that best describes you. Please select one.
____ Undemanding:
Quiet for long periods of time almost every day
Almost never:
- talk for long periods
- raise your voice above a conversational level,
- participate in group discussions, give a speech or other presentation
____ Intermittent:
Quiet for long periods of time on many days
Most talking is typical conversational speech
Occasionally:
- talk for longer periods
- raise voice above conversational level
- participate in group discussions, give a speech or other presentation
____ Routine:
Frequent periods of talking on most days
Most talking is typical conversational speech
Occasionally:
- talk for longer periods
- raise voice above conversational level
- participate in group discussions, give a speech or other presentation
____ Extensive:
Speech needs consistently go beyond everyday conversational speech.
Regularly:
- talk for long periods
- talk in a loud voice
- participate in group discussions, give presentations or performances
Although the demands on your speech are often high, you are able to continue with most
work or social activities even if your speech is not perfect.
____ Extraordinary:
Very high speech demands
Regularly:
- talk for long periods of time
- talk with loud or expressive speech or
- give presentations or performances.
The success of your work or personal goals depends almost entirely on the quality of your
speech and voice.
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7!
Please list any leisure activities you regularly participate in outside your professional life:
Please feel free to add any additional information that you feel is relevant to your voice or any
scheduling issues:
Thank you for taking the time to fill this application. It will help us provide the best services we can for
you. Please continue and complete the questionnaires that follow.
Voice&Intake&Form&
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8!
Voice Handicap Index-10 (VHI-10)
1
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Name: _______________________________________________ Date: ________________________
These are statements that many people have used to describe their voices and the effects of their voices on
their lives. Circle the response that indicates how frequently you have the same experience.
0 – never 1 – almost never 2 – sometimes 3 – almost always 4 – always
0 1 2 3 4
1. My voice makes it difficult for people to hear me ____ ____ ____ ____ ____
2. People have difficulty understanding me in a noisy room ____ ____ ____ ____ ____
3. My voice difficulties restrict personal and social life ____ ____ ____ ____ ____
4. I feel left out of conversations because of my voice ____ ____ ____ ____ ____
5. My voice problem causes me to lose income ____ ____ ____ ____ ____
6. I feel as though I have to strain to produce voice ____ ____ ____ ____ ____
7. The clarity of my voice is unpredictable ____ ____ ____ ____ ____
8. My voice problem upsets me ____ ____ ____ ____ ____
9. My voice makes me feel handicapped ____ ____ ____ ____ ____
10. People ask, “What’s wrong with your voice?” ____ ____ ____ ____ ____
Total Score: _______
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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1
Rosen, C., et al. Development and validation of the Voice Handicap Index-10. Laryngoscope 114, 2004.
Voice&Intake&Form&
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Singing Voice Handicap Index-10 (SVHI-10)
2
Name: _________________________________________ Date: ________________________
These are statements that many people have used to describe their singing and the effects of their singing on
their lives. Circle the response that indicates how frequently you have the same experience in the last 4
weeks.
0 – never 1 – almost never 2 – sometimes 3 – almost always 4 – always
0 1 2 3 4
1. It takes a lot of effort to sing ____ ____ ____ ____ ____
2. I am unsure of what will come out when I sing ____ ____ ____ ____ ____
3. My voice “gives out” on me while I am singing ____ ____ ____ ____ ____
4. My singing voice upsets me ____ ____ ____ ____ ____
5. I have no confidence in my singing voice ____ ____ ____ ____ ____
6. I have trouble making my voice do what I want it to ____ ____ ____ ____ ____
7. I have to “push it” to produce my voice when singing ____ ____ ____ ____ ____
8. My singing voice tires easily ____ ____ ____ ____ ____
9. I feel something is missing in my life because of my inability to sing ____ ____ ____ ____ ____
10. I am unable to use my “high voice” ____ ____ ____ ____ ____
Total Score: _______
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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2
Cohen, S., et al. Development and Validation of the Singing Voice Handicap Index-10. Laryngoscope 119, 2009.
Voice&Intake&Form&
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10!
Name: _________________________________________ Date: ________________________
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Reflux Symptom Index (RSI)
3
Within the last month, how did the following problems affect you? Mark the appropriate response.
0 = No Problem 5 = Severe Problem
1
2
4
5
1. Hoarseness or a problem with your voice
2. Clearing your throat
3. Excess throat mucus or postnasal drip
4. Difficulty swallowing food, liquids, or pills
5. Coughing after you ate or after lying down
6. Breathing difficulties or episodes
7. Troublesome or annoying cough
8. Sensations of something sticking in your throat or a lump in your throat
9. Heartburn, chest pain, indigestion, or stomach acid coming up
Total Score
Glottal Function Index (GFI)
4
Within the last month, how did the following problems affect you? Mark the appropriate response.
0 = No Problem 5 = Severe Problem
1
2
4
5
1. Speaking took extra effort
2. Throat discomfort or pain after using your voice
3. Vocal fatigue (voice weakened as you talked)
4. Voice cracks or sounds different
Total Score
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3
Belafsky, P., Postma, G., and Koufman, J. Validity and reliability of the reflux symptom index. Journal of Voice.
2002;16:274-278.
4
Bach, K., Belafsky, P, Wasylik, K, Postma, G., & Koufman, J. Validity and Reliability of the Glottal Function Index.
Archives of Otolaryngology Head & Neck Surgery. 2005;13:961-964.
Voice&Intake&Form&
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11!
Vocal Fatigue Index
5
!
Name: _________________________________________ Date: ________________________
These are some symptoms usually associated with voice problems. Circle the response that indicates how
frequently you experience the same symptoms.
0 – never 1 – almost never 2 – sometimes 3 – almost always 4 – always
0 1 2 3 4
Part 1
1. I don’t feel like talking after a period of voice use _____ _____ _____ _____ _____
2. My voice feels tired when I talk more _____ _____ _____ _____ _____
3. I experience increased sense of effort with talking _____ _____ _____ _____ _____
4. My voice gets hoarse with voice use _____ _____ _____ _____ _____
5. It feels like work to use my voice _____ _____ _____ _____ _____
6. I tend to generally limit my talking after a period of voice use _____ _____ _____ _____ _____
7. I avoid social situations when I know I have to talk more _____ _____ _____ _____ _____
8. I feel I cannot talk to my family after a work day _____ _____ _____ _____ _____
9. It is effortful to produce my voice after a period of voice use _____ _____ _____ _____ _____
10. I find it difficult to project my voice with voice use _____ _____ _____ _____ _____
11. My Voice feels weak after a period of voice use _____ _____ _____ _____ _____
Total Score: _______
Part 2
12. I experience pain in the neck at the end of the day with voice use _____ _____ _____ _____ _____
13. I experience throat pain at the end of the day with voice use _____ _____ _____ _____ _____
14. My voice feels sore when I talk more _____ _____ _____ _____ _____
15. My throat aches with voice use _____ _____ _____ _____ _____
16. I experience discomfort in my neck with voice use _____ _____ _____ _____ _____
Total Score: _______
Part 3
17. My voice feels better after I have rested _____ _____ _____ _____ _____
18. The effort to produce my voice decreases with rest _____ _____ _____ _____ _____
19. The hoarseness of my voice gets better with rest _____ _____ _____ _____ _____
Total Score: _______
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
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5
Nanjundeswaran, C., et al. Vocal Fatigue Index (VFI): Development and Validation. Journal of Voice 29:4, 2015.
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