Patient History: Singers Name Date______________________
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Patient History: Singers Name _________________________________________ Date______________________ Age___________ Birthddate_____________ Height _____________ Weight ____________ Sex _____ Ethnicity Caucasian East Asian Native American Soprano Tenor Voice Category African-American West Asian Other ______________ Mezzo soprano Baritone Hispanic Middle Eastern Alto Bass 1. How long have you had your voice problem? _________________ 2. Who noticed it? Self Family Voice teacher Other _____________________ 3. Do you know what caused it? Yes 4. Did it come on slowly or suddenly? 5. Is it getting Worse No Everyone If yes, what?__________________________ Slowly Suddenly Better Unchanged 6. What voice problems are you having? (check all that apply) Hoarseness (coarse or scratchy sound) Vocal fatigue (voice tires or changes quality after a short period of singing or talking) Trouble singing softly Trouble singing loudly Decreased range High Middle Low Prolonged warm-up time (over ½ hour to warm up voice Breathiness Vocal instability Difficulty with register transitions Throat tickle or choking while singing Pain in throat while singing or talking Poor pitch control Difficulty with breath support Intermittent voice breaks 7. Have you ever had problems with your voice in the past? If yes, please describe (check all that apply) Yes No Laryngitis Polyps Swelling/edema Hemorrhage Thrush Paresis Nodules Cysts Tear Papilloma Cancer Other__________________________ 8. Have you ever had voice surgery? Yes If yes, when?___________________________ What kind of surgery? (check all that apply) Removal of polyp Removal of nodules Removal of cancer Injection of collagen Thyroplasty No Removal of cyst Removal of papilloma Injection of steroids Other vocal fold injection (describe)______________ Other (describe)______________________________ 9. Do you have any of the following problems? (check all that apply) Throat Voice worse in the morning Voice worse later in the day, after it has been used Frequent throat clearing Frequent sore throat Jaw joint problems Bitter or acid taste in mouth Bad breath Heartburn Rare Occasional Frequent Chronic fatigue Frequent thirst Chronic cough Post-nasal drainage Cough while sleeping Difficulty swallowing Sensation of something stuck in throat Sensation of swelling in throat Frequent yelling/screaming Frequent talking over background noise or in a noisy environment Excessive talking Work in extreme dryness Work around dust or mold Live in or work around smoke or fumes Nose Nasal congestion Nasal drainage Clear Yellow Green Unable to breathe through nose Pressure at bridge of nose Facial pressure Pressure in forehead Headache Forehead Behind eyes Temples Back of head Sneezing Itchy nose Snoring Light Moderate Loud Eyes Blurry vision Double vision Itchy eyes Watery eyes Dry eyes Ears Decreased hearing Ringing in ears Dizziness Room spinning Drainage from ears Pain in ears Imbalance Neck Lump in neck Pain in neck General Fatigue/Tiredness More stress than normal currently Fevers Chills Night sweats Weight loss Weight gain Fall asleep easily Stop breathing while sleeping Chest pain Brown Top of head Shortness of breath Abdominal pain Nausea Vomiting Diarrhea Constipation Back pain Neck pain Numbness/Tingling Hands Muscle aches Joint pains Depressive feelings Anxiety or jitteriness Palpitations or rapid heartbeat Arms 10. Do you have an important performance soon? If yes, when?___________________________ 11. What is the current status of your singing career? Professional Avocational (2nd job) Legs Feet Yes No Amateur Singing Student 12. What are your longterm career goals in singing? Operatic career Active avocation Pop career Choral performance Recording artist Solo performance Musical theater Amateur singing for own pleasure Wedding singer Singing teacher 13. Did you study voice as a major or minor in college? Yes No 14. Have you ever had voice lessons? Yes No For how many years total?_______________________________________________________ How old were you when you started?______________________________________________ How long has it been since your last voice lesson?____________________________________ How long have you been studying with your current voice teacher?______________________ 15. Have you ever had training for your speaking voice? 16. Have you ever had acting voice lessons? Yes Yes 17. Have you ever had voice therapy or speech therapy? No No Yes No 18. Do you have a job in addition to singing? Yes No If yes, does it involve extensive use of your voice? Yes No What is the job? _______________________________________________________________ How many hours per day do you use your voice at work?______ _______________________ 19. How much time do you spend in singing rehearsals? ______________ hours for ______________ days per week 20. How much time do you spend performing? _____________hours for ______________ days per week For how many weeks at a time are you performing?____________________ How many times per year?_________________________ 21. What kind of music do you sing? Classical Cabaret Hard Rock R&B Jazz Gospel Country Musical theater Show Light Rock Hip Hop Rap Spiritual Other _________________________ 22. Do you warm up your voice before you sing? Yes For how long? _________________________________ No 23. Do you warm down your voice before you sing? Yes For how long?____________________________________ No 24. Do you play a musical instrument regularly? Yes No If yes, which one/ones?___________________________________________________________ 25. Are your menstrual periods regular (females only)? Yes No If no, is there a medical reason? Yes No What is the reason? ___________________________________________________________ 26. Do you smoke cigarettes? Yes No Quit in (enter year)________________ How much do you/did you smoke? _____________packs per day for ________________ years 27. How much alcohol do you drink? _________# drinks per day week month year 28. Have you ever used recreational drugs? Yes No If yes, are you using them currently or use was in the past? Currently In the past When did you last use drugs? _____________________ What drugs do/did you use? Cocaine Marijuana Snort Heroin Smoke Meth (crystal meth, methamphetamines) Free-base Narcotics (Percocet, oxycodone, oxycontin, etc.) Inject Barbituates Crack Speed Crank Downers Other _________________________ 29. Are you allergic to any medications? Penicillin Amoxicillin Cephalosporins Tetracycline Sulfa Erythromycin 30. Have you been allergy tested? If yes, to what are you allergic? Mold Cats Animal dander Trees Weeds Lidocaine/Novocaine Iodine IV contrast dye/X-ray dyes Latex Adhesive tape Other ________________________________ Yes No Dust Dogs Cockroaches Grasses Other ______________________________________ 31. Do you have or have you ever had any of the following medical conditions? (check all that apply) Diabetes Hypoglycemia High blood pressure Asthma Low blood pressure COPD or emphysema Migraines Headaches Seasonal allergies Sinus infections Allergies Angina Heart disease History of heart stent or bypass Heart valve disease History of heart valve replacement Atrial fibrillation (A fib) Irregular heartbeat Hypothyroidism (low thyroid) Hyperthyroidism (high thyroid hormones) Arthritis C-spine problems T-spine problems Lumbosacral (LS) spine problems GERD/reflux disease Hiatal hernia Ulcers (stomach or duodenum) Breast cancer Lung cancer Prostate cancer Skin cancer Other cancer (explain) __________________ Cold sores Genital warts Herpes Syphilis Gonorrhea HIV AIDS Hepatitis A B C Heart attack Stroke TIA Aneurysm bleed Kidney failure Urinary tract infections Seizures Anxiety Depression ADD or ADHD Panic Attacks Rheumatic fever Thyroid nodules Heavy menstrual periods Menopause Pregnant Other ________________________________________________________________ 32. What medical problems run in your family? (check all that apply) High blood pressure Thyroid problems Heart disease Cancer (type)______________________ Heart attack Reflux/Hiatal hernia/heartburn High cholesterol Asthma Other ________________________________________________________________ 33. What surgical procedures have you had and in what year? Surgery Tonsillectomy Adenoidectomy Sinus surgery Vocal fold surgery Thyroplasty Septoplasty Rhinoplasty Appendectomy Gall bladder Heart stent Heart bypass Carotid surgery Other (please list) Year
