Voice Questionnaire

Please circle the number corresponding to your agreement with the following statements. 0=Strongly Disagree 1=Disagree 2=Undecided 3=Agree 4=Strongly Agree
Initials: Last four digits of SSN:
	0	1	2	3	4
My voice makes it difficult for people to hear me
People have difficulty understanding me in a noisy room
My voice difficulties restrict personal and social life
I feel left out of conversations because of my voice
My voice problem causes me to lose income
I feel as though I have to strain to produce voice
The clarity of my voice is unpredictable
My voice problem upsets me
My voice makes me feel handicapped
People ask, "What's wrong with your voice?"
I have told others with spasmodic dysphonia about this operation
I am not embarrassed speaking in public
My speech is understandable
Botox has treated my spasmodic dysphonia successfully
I currently experience difficulty breathing
I currently experience swallowing difficulties

Head and Neck Surgery Division

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