Voice evaluation registration packet
Voice evaluation registration packet
Voice evaluation registration packet
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II. EDUCATION/SOCIAL HISTORY<br />
Highest level of schooling completed (please circle one):<br />
Grade School High School Trade School College Graduate Doctorate Other: ___________<br />
Are you currently employed? ___YES ___NO Do your symptoms interfere with your ability to do your job? ___YES ___NO<br />
Current/Past Occupation: ___________________________________________________________________________________<br />
Are you retired? ___YES<br />
___NO If so, for how long? ________________________________________________________<br />
If student, please list grade, school attending, and teacher/speech-language pathologist:___________________________________<br />
_________________________________________________________________________________________________________<br />
Name of school / daycare provider (in home/out of home):__________________________________________________________<br />
Please list any sports/community activities or hobbies you enjoy: __________________________________________________<br />
_________________________________________________________________________________________________________<br />
III. MEDICAL HISTORY<br />
What symptoms/problems led you to request this <strong>evaluation</strong>?<br />
__________________________________________________________________________________________________________<br />
Date of onset (month, day, year problem was first noticed): _________________________________________________________<br />
Has this problem improved/deteriorated since the onset? Please Explain:<br />
__________________________________________________________________________________________________________<br />
Have you been treated for this problem before? ___YES<br />
___NO<br />
If yes, state where: _____________________________________ Approximately when: ________________________<br />
Treatment given: ________________________________________________________________________________<br />
Was the treatment successful? ___YES<br />
___NO<br />
Have you had surgery/medical treatment for this problem before? ___YES<br />
___NO<br />
If yes, please list the approximate date and type of surgery/medical treatment: ___________________________________________<br />
List any other major medical illness or surgery that has occurred (may attach separate sheet, if needed)_______________________<br />
__________________________________________________________________________________________________________<br />
__________________________________________________________________________________________________________<br />
Are you currently taking ANY medications? ___YES<br />
___NO<br />
If YES, please complete the following regarding medications: (Please use back of form if necessary)<br />
MEDICATION REASON FOR TAKING SIDE EFFECTS<br />
MEDICATIONS<br />
EXPERIENCED<br />
___________________________ ________________________ _______________________<br />
___________________________ ________________________ _______________________<br />
___________________________ ________________________ _______________________<br />
___________________________ ________________________ _______________________<br />
___________________________ ________________________ _______________________<br />
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