Name_______________________ DOB____________ Age____________ Date___________
Referred by______________________________ Medical Dx__________________________
Complaint as stated by patient_____________________________________________________

I.  HISTORY/INTERVIEW

 A.  History of Problem ( onset, duration, prior episodes, treatment, effect)
 
 
 
 
 
 
 

 B.  Voice Symptom History:

 1.  Variability/Consistency (use related, situational, physical well-being, time of the day)
 
 
 
 

 2.  Associated Symptoms and Sensations (pain, dryness, tickle, lump, strain, fatigue,
                dysphagia, weight loss, heartburn, slurred speech)
 
 
 
 

 C. Voice Use History:

  1.  Talking (how much, when, how, to whom)
 
 
 
 

  2.  Other Voice Use (singing, acting, sound effects, throat clear)
 
 
 
 

 D.  Health History:

   1.  Present Health (neurological, respiratory, allergy, psychiatric, gastrointestinal,
                   endocrine/hormonal, chronic conditions)
 
 
 
 
 
 
 

   2.  Past Health (relevant to present problem)
 
 
 
 

   3.  Surgery (laryngeal, thyroid, cardiac, thoracic, intubation)
 
 
 
 

   4.  Trauma/substance or environmental exposure (accident, chemical ingestion, smoke,
                    noxious gases, inhalation, noise)
 
 
 
 

   5.  Substance use: (tobacco, alcohol, medicines, illicit drugs)
 
 
 
 

 E.  Social, occupational, recreational history (family constellation, living arrangements,
                  life style, job description, exercise programs, hobbies)
 
 
 
 
 

II.  HEARING SCREENING:    Pass/Fail
 1.  Begin at 25 dB
 2.  Test 500, 1K, 2K, 4K
 
 

III.  ORAL PERIPHERAL EXAM (optional)
 A.  Structures: (Note any structural abnormalities, asymmetries, weakness, deviations, etc.)
 
 
 
 

 B.  Diadochokinetic Rate (Means in Kent, 1994)
  1. /p   / productions per 5 sec           ___________
  2. /t   / productions per 5 sec  ___________
  3. /k   / productions per 5 sec  ___________
  4.  SMR per 10 secs   ___________
 

IV.  PERCEPTUAL ASSESSMENT ( tape record)
 A.  Speech Sample
  1.  Standard reading passage (Rainbow or Grandfather)
  2.  Stress test (counting to 200, say months of year in one breath)
  3.  Short dialogue
  4.  Analyze using Wilson Voice Profile or other tool. ( Rate the quality, tone,
                             pitch, intensity, nasality, tone focus, inflection/vocal range, rate )

Results:
 
 
 
 
 
 

 B.  Glottal Coup
       1.  Instruct client to cough ________ Abrupt ________ Mushy
       2.  Instruct client to clear throat   ________ Abrupt ________ Mushy
 

 C.  Glottal Attack _______ Normal   _________ Weak  ________ Hard
 

 D.  Respiration
  1. At rest:   _______ Abdominal________Clavicular________Thoracic
  2. During phonation  _______ Abdominal _______Clavicular________Thoracic
  3. Speaking on residual air:        ________ yes    _________ no
  4. Speaking during inspiration:   ________ yes    _________ no
 

 V.  VOCAL FUNCTION TESTING
 A.  Forced Vital Capacity (FVC) [take 3 trials; use best score for further calculations and for final report]

      1._________________ 2._________________ 3._________________
 

 B.  Predicted Forced Vital Capacity (calculate later - formula in handout)
       1.  Ht. of client in cm _________ (ex. 5'8" 68 in X 2.54 = 172.7 cm)
       2.  Age of client        _________
       3.  PFVC = ________________
 

 C.  Maximum Phonation Time (MPT) [3 trials, report best score  - can be measured using stopwatch or using Visapitch]

         /a/      1._________________ 2._________________ 3._________________

        /i/       1._________________ 2._________________ 3._________________
 

 D.  Predicted Maximum Phonation Time (calculate later)

       1.  PMPT = ___________

        2. MPT/PMPT = _____________
 

 E.  s/z ratio ( 3 trials; alternate sets of trials - use best /s/ and best /z/ to calculate ratio)

        /s/        1._________________ 2._________________ 3._________________

        /z/        1._________________ 2._________________ 3._________________
 

 F.  Intensity Measures

        Dynamic range:   low _________ dB       high___________dB    Range  __________dB (high - low)

        Avg. speaking intensity:  _____________ dB
 

 G.  Maximum Phonational Frequency Range

        low__________Hz     High___________ Hz   Range  __________ST ( high - low in semitones)
 

 H.  Speaking Fundamental Frequency ( reading passage; conversation)

        Average (Mean)   ___________ Hz

        Variability/Pitch sigma: (standard deviation)  __________Hz

        Convert to semitones :  ____________ ST
 

 I.  Perturbation Measures (3 trials & take avg; use comfortable pitch, slightly higher & slightly lower, measure 3 secs from middle of vowel)

          /i/    Jitter __________ shimmer  _______ f0 _________   %voiced energy_______

         /i/    Jitter __________ shimmer  _______ f0 _________   %voiced energy_______

        /i/    Jitter __________ shimmer  _______ f0 _________   %voiced energy_______
 
 

 J.  MDVP (sustained /a/ - 3 trials & take avg.; note areas outside threshold on the graph; print numerical results)
 
 
 
 
 
 
 
 

 K.  Phonation Quotient, Estimated Mean Flow Rate (calculate using formulas on handout)

        PQ  _______________________
 

        EMFR _____________________
 
 

G  Musculoskeletal Tension (Assess using digital manipulation & )
  1.  Laryngeal pain:                  yes          no              unilateral/bilateral

  2.  Chest pain                         yes          no              reported

  3.  Tongue elevation                  normal         elevated

  4.  Larynx/.hyoid elevation        normal         elevated

  5.  Thyrohyoid space                normal         reduced

  6.  Resistance to mvmt.             normal         increased

  7.  Voice improvement
         on sustained /a/                 yes          no              slight
 

 F.  Modification of Vocal Behavior (list techniques used and effect if any)