Adult Voice Intake
Case History For Patient to fill out
Background Information
Client's name:
*
First Name
Last Name
Client's date of birth
*
-
Month
-
Day
Year
Date
Today's birth
*
-
Month
-
Day
Year
Date
Client's age:
*
Gender
*
Male
Female
Other
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Marriage Status
Single
Married
Widowed
Divorce
If under 18 years old, Name of parent/guardian
First Name
Last Name
Are you receiving any assistance at home, including home health services?
Yes
No
If yes, describe services:
Languages spoken:
Are you currently driving?
Yes
No
What level of eduction do you have?
Occupation
Current status:
Employed
Retired
Unemployed
Other
Name of referring physician
Physician's phone number
Please enter a valid phone number.
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Medical Background
Check what applies to you
Arthritis
Asthma
Bronchitis
Blood sugar high
Blood sugar low
Diabetes
Headaches
Heartdisease
High blood pressure
Kidney disease
Bladder disease
Liver damage
Lung disease
Joint/bone disease
tuberculosis
Cancer/treatment
Thyroid disease/surgery
Neurologic disorder
Depression
Bleeding problems
Stroke
GI disorders
Sinus disease
Endocrine disorder
Hearing loss
I wear hearing aids
I am currently pregnant
I am currently in menopause
I am post menopausal
I have regular menstral cycles
I have voice changes during cycles
Allergies
None of the above
Other
Add details regarding medical history; e.g. diagnoses, surgeries, dates:
What specialists do you follow?
List medications currently taking
Do you have a hearing impairment?
Yes
No
If yes, please explain:
Do you have a vision impairment?
Yes
No
If yes, please explain:
Do you have any pain currently?
Yes
No
Please explain:
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Vocal Hygien
I drink
ounces of water daily.
I drink
ounces of caffeine daily.
I drink
ounces of alcohol daily.
I smoke currently:
Yes
No
I have a history of smoking:
Yes
No
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Parkinson's
Do you have a diagnosis of Parkinson's disease?
Yes
No
Who is your nuerologist?
Do you have tremors?
Yes
No
Please explain:
Are you taking medication for Parkinson's
yes
No
Is the Parkinson's medication affecting your voice/speech?
Yes
No
Do you experience "on"/"off" symptoms?
Yes
No
Please explain
Do you experience dyskinesia
Yes
No
Please describe:
When did you first notice communication symptoms that you associate with Parkinson disease?
What are you current symptoms
Do people ask you to repeat?
Yes
No
What do you do when you want to be as easy to understand as possible?
what percentage of your speech do you think is intelligibile (i.e., people CAN understand you)?
Has parkinson's caused you to speak less? if yes, how much less?
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Functional
Onset
Sudden
gradual
What is the MOST SIGNIFICANT PROBLEM communicating today?
How do you typically use your voice during the day?
How many hours of speaking do you do in a day?
Signature
Swallowing
Please describe your swallowing difficulties
Submit
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