New Patient Voice & Swallowing Questionaire
2415 Musgrove Road, Suite 203
Silver Spring, Maryland 20904
(301) 989-2300
Please use the exact same name that you used to schedule the appointment
Patient’s First Name
*
Last Name
*
MI
Birth Date
*
Provider
*
Please Select
Valerie Asher, MD
David Bianchi, MD
Brian Driscoll, MD
Liesl Nottingham, MD
Hosai Todd-Hesham, MD
Mark Miller, MD
Unknown/Unlisted
Address
*
City
*
State
*
Zip
*
All Patients – RSI
Please rate each question from 0-5 using the description: 0 = no problem, 5 = severe problem
1. Hoarseness or a problem with your voice
0
1
2
3
4
5
2. Clearing your throat
0
1
2
3
4
5
3. Excess throat mucous or postnasal drip
0
1
2
3
4
5
4. Difficulty swallowing food, liquid, or pills
0
1
2
3
4
5
5. Coughing after you ate or after lying down
0
1
2
3
4
5
6. Breathing difficulties or choking episodes
0
1
2
3
4
5
7. Troublesome or annoying cough
0
1
2
3
4
5
8. Sensation of something sticking in throat or a lump in your throat
0
1
2
3
4
5
9. Heartburn, chest pain, indigestion or stomach acid coming up
0
1
2
3
4
5
Voice Problems – VHI-10
Are you having trouble with your voice?
Yes
No
1. How would you describe your voice?
2. What makes your voice better?
3. What makes your voice worse?
4. Is there a time of day your voice is best?
Morning
Midday
Evening
5. Do you ever have a normal voice?
Yes
No
When?
6a. How many 8 oz. glasses of water do you drink daily?
6b. How many servings of caffeine daily?
7. Please check any of the following that describe your problems related to your voice
Pain with talking
Strain with talking
Triggers cough
Unreliable sound/quality
Quiet/low volume
High pitch
Low pitch
Increased effort/tire easily
Feel short of breath
Voice cracks
Difficulty singing - High range
Mid-range
Low range
Transition
8. Do you sing in any capacity?
Yes
No
8a. Do you sing
Professionally
Recreationally
b. How many years of training have you completed?
c. What are your aspirations as a singer?
d. What is your style of singing?
e. How many hours (on average) per week do you spend singing?
Please rate each question from 0-4 using the description: 0 = no problem, 4 = severe problem
1. My voice makes it difficult for people to hear me
0
1
2
3
4
2. People have difficulty understanding me in a noisy room
0
1
2
3
4
3. My voice problems alter my personal and social life
0
1
2
3
4
4. I feel left out of conversations because of my voice
0
1
2
3
4
5. My voice problem affects my work performance
0
1
2
3
4
6. I need to strain to produce my voice
0
1
2
3
4
7. The quality of my voice is unpredictable
0
1
2
3
4
8. My voice bothers me
0
1
2
3
4
9. People seem irritated with my voice
0
1
2
3
4
10. People ask, “What’s wrong with your voice?”
0
1
2
3
4
Breathing or Coughing Problems
Are you having trouble with your breathing (e.g. short of breath, noisy breathing, cough)?
Yes
No
1. What makes you short of breath?
2. What makes you feel better?
3. Is your breathing noisy?
Yes
No
4. What was your activity/exercise level before this started?
5. Do you have trouble with cough?
Yes
No
6. If so, what are the triggers or when does it happen?
7. How long does it last?
8. What makes it stop?
Swallowing Problems – EAT-10
Are you having trouble with your swallowing?
Yes
No
1. Is swallowing painful?
Yes
No
1a. What is difficult to swallow?
Solids
Liquids
Pills
1b. What foods specifically?
2. What do you avoid eating/drinking due to this problem
3. Do you feel like you are choking or cough when you swallow?
Yes
No
4. When is swallowing hardest during the day
5. Have you had pneumonia in the past year?
Yes
No
6. Have you lost weight?
Yes
No
Please rate each question from 0-4 using the description: 0 = no problem, 4 = severe problem
1. My swallowing problem has caused me to lose weight
0
1
2
3
4
2. My swallowing problem interferes with my ability to go out for meals
0
1
2
3
4
3. Swallowing liquids takes extra effort.
0
1
2
3
4
4. Swallowing solids takes extra effort
0
1
2
3
4
5. Swallowing pills takes extra effort
0
1
2
3
4
6. Swallowing is painful
0
1
2
3
4
7. The pleasure of eating is affected by my swallowing
0
1
2
3
4
8. When I swallow food sticks in my throat
0
1
2
3
4
9. I cough when I eat
0
1
2
3
4
10. Swallowing is stressful
0
1
2
3
4
What other questions, comments, or concerns do you have regarding this problem?
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Date