FORM – Musser Voice Intake form

Please provide the following information as accurately and completely as possible.

This information is very important to your care.

Today's Date

Preferred Name

First Last

Legal Name

First Last

Date of Birth

Age

Occupation

Home Phone

Work Phone

Referring physician

Family physician

Date of next appointment with referring physician:

What is your chief complaint? Please Select All that Apply:

(Hold down the CTRL key to select multiple complaints)

Other chief complaint(s)?

Have you ever received voice therapy in the past?

Yes
No

Medication

(Please list any medication you are taking – include prescription, over-the-counter, herbal.) * If you provide a list, we will make a copy

Medication Allergies and Environmental Allergies

(e.g. hay fever, pollen, mold, dust, foods, etc.) (Indicate if you have had an allergy test and the results.)

Are you a professional (singer/actor/TV/radio) or semi-professional (clergy/educator/choir) voice user?

Yes
No

If Yes, please define:

Indicate whether or not you have ever had any of the following:

Do you currently smoke?

Yes
No

Smoking type

Smoking - define 'other':

How many per day/week?

How long?

Are you a past smoker?

Yes
No

How many per day/week?

Quit when & smoked how long?

Recreational drug use?

Alcohol intake?

(indicate type and amount)

Daily intake of: Water

Daily intake of: Juices

Daily intake of: MIlk

Daily intake of: Coffee

Daily intake of: Tea

Daily intake of: Soda

Daily intake of: Chocolate

Within the past month, how did the following problems affect you?

1) Hoarseness or a problem with your voice (chronic or intermittent, vocal fatigue or voice breaks)

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

2) Clearing your throat (often excessive)

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

3) Excess throat mucus or post nasal drip

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

4) Difficulty swallowing food, liquids or pills (dysphagia)

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

5) Coughing after you ate or after lying down

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

6) Breathing difficulties or choking episodes (wheezing, and/or airway obstruction)

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

7) Troublesome or annoying cough

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

8) Sensations of something sticking in your throat or a lump in your throat

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

9) Heartburn, chest pain, indigestion, or stomach acid coming up (regurgitation)

1 = no problem
2 = a small amount
3 = a medium amount
4 = a lot
5 = severe-as bad as it can be

Within the last month, how have the following problems affected you?

1) Speaking took extra effort

2) Throat Discomfort/Pain

3) Vocal fatigue

4) Voice sounds different/cracks