Voice/Vocal Fold Questionnaire
History
Describe your present voice concerns/problems:_____________________________
__________________________________________________________________
When did your symptoms start? _________________________________________
What seemed to cause symptoms? ______________________________________
Anything else going on at the time? (i.e. illness, stress, medicine changes,
environment changes, etc) _______________________________________________________
__________________________________________________________________
Review of Symptoms
How do your symptoms hurt you or affect you? _______________________________
Is there a pattern to your symptoms? (i. e. worse in a.m. or p.m., voice use
situation, seasons, etc) _______________________________________________________
__________________________________________________________________
What aggravates your symptoms? ________________________________________
What improves your symptoms? _________________________________________
What sites of your head and neak are also involved?__________________________
__________________________________________________________________
Check the symptoms you experience:
| ____ hoarseness |
____ tightness in neck/throat |
____ heartburn |
| ____ coughing | ____ burning in back of throat | ____ difficulty swallowing |
| ____ bleeding | ____ shortness of breath | ____ dry throat |
| ____ post-nasal drip | ____ frequent throat clearing |
Have you had any injuries to head
or neck? _________________________________
Check any of the following conditions that you have:
| ___ asthma | ___ environmental allergies | ___ diabetes |
| ___ acid reflux | ___ thyroid problems | ___ excess stress |
| ___digestive problems | ___peri- or postmenopausal problems |
Social
What is your occupation? _______________________________________________
Describe how you use your voice at work. __________________________________
Do you have any hobbies that involve voice use? _____________________________
Do you or have you ever smoked? ________ packs per day __________ yrs_______
How many 8 oz servings do you have of the following in a typical day:
| ____ water | ____ caffeninated drinks like cola or coffee |
| ____ alcoholic drinks | ____ acidic juices |
| ____ milk or dairy drinks |
Are you exposed to chemicals, paint, glue, gases, fumes excess dust, etc? _________
Singers
How do you classify you voice?
| ___ Soprano | ___ Mezzo | ___ Alto | ___ Tenor | ___ Baritone | ___ Bass |
How do you sing?
| ____ solo | ____ small group | ____ choir | ____ band | other________ |
Name of group(s) you sing in: ___________________________________________
Style(s) of music that you sing: __________________________________________
Do you consider yourself:
| ____ Amateur | ____ Semi-Professional | ____ Professional |
Do
you play instruments while singing? Yes No
What instruments? ___________________________________________________
Do you currently take singing lessons? Yes No
Who is your singing teacher? _______________________ Phone_______________
Describe your singing lesson history: ______________________________________
__________________________________________________________________
__________________________________________________________________
How often do you perform? _____________________________________________
How often do you practice? _____________________________________________
Do you warm up before singing? __________ Do you cool down after? ___________
Check all that apply:
| ____ lost higher notes |
| ____ lost lower notes |
| ____ unable to sing loudly |
| ____ unable to sing softly |
| ____ can’t sustain pitch accurately |
| ____ difficulty with breaks/register transitions |
| ____ run out of breath quickly |
| ____ fatigue easily |
| ____ become hoarse after singing |
Other____________________________ ________________________________ |