Health History Form

Personal History

The following form is a chance for me to learn a bit about you, your voice and what you’ve experienced in your life to this point. These questions provide a shortcut for me to figure out how to work with you most efficiently and effectively. The information you provide is 100% confidential; that being said, if there’s something you’d rather not write down, no pressure at all. If you don't want to fill this form out online, you can download and print it here; then, you can bring the completed form to your lesson. Thanks!

Name:

Email address:

Vocal History

Have you experienced/do you experience any of the following?

Clearing your throat/phlegm: NeverRarelySometimesOftenConstantly
Heartburn: NeverRarelySometimesOftenConstantly
Trouble Swallowing: NeverRarelySometimesOftenConstantly
Post-nasal drip/sinus issues: NeverRarelySometimesOftenConstantly
Allergies: NeverRarelySometimesOftenConstantly
Sore jaw/TMJ issues: NeverRarelySometimesOftenConstantly
Asthma: NeverRarelySometimesOftenConstantly

Are any of the following part of your vocal history?

Vocal nodules: YesNoMaybe/not sure
Pre-nodular swelling: YesNoMaybe/not sure
Vocal polyp or vocal cyst: YesNoMaybe/not sure
Chronic laryngitis: YesNoMaybe/not sure
Vocal hemorrhage: YesNoMaybe/not sure
Vocal surgery: YesNoMaybe/not sure

If you answered yes to any of the above, can you tell me when it happened and a little about the circumstances:

Health history: (please include anything that you are comfortable sharing, even if it doesn’t seem relevant to your voice. If you broke your big toe, I’d like to know about it.)

Major surgeries:

Broken bones/fractures:

Sprains/torn ligaments/tendons:

Accidents:

Concussions/head injuries:

Major illness:

Scars/Tattoos:

Dental work:

Areas of chronic tension:

Other Health Information

Do you take any medications or supplements regularly?

What do you do for exercise?

Do you wear glasses/contacts? YesNoGlasses onlyContacts only

Any vision problems that you are aware of (blurry vision, dry eyes, tunnel vision, eye twitching, lazy eye, etc.)?

Any history of ear infections/hearing problems?

Approximately how many hours of sleep do you get a night (on average)? 10 or more8-96-74-53 or less

How would you rate the quality of your sleep? ExcellentGoodFairPoorI don't sleep

Any stomach/digestion/GI issues?

Anything else you’d like me to know?

Thank you for taking the time to fill this questionnaire out!