Voice Disorder Therapy Intake

Personal Information

Full Name Date of Birth Phone Number Email Address Address

Referral & History

How did you hear about our clinic? Reason for referral / Main concern Duration of symptoms Previous diagnosis (if any)

Medical & Voice History

Relevant medical history (e.g., surgeries, illnesses) Voice use (occupation, hobbies) Onset and pattern of voice disorder Factors that improve or worsen the condition Current medications Have you seen an ENT/laryngologist? Yes No

Voice & Communication Impact

How does your voice problem impact daily life? Specific situations where you struggle the most

Therapy Goals

Your goals or expectations from therapy