The Inquiry Form for Phoniatrics Consultation

The Inquiry Form for Phoniatrics Consultation

语音矫正法咨询表

Items with asterisk * are mandatory. Please be sure you fill out these items.
Name*
姓名
Email*
电子邮件
Sex*
性别
Date of birth*
出生日期
,
Nationality
国籍
Phone Number
* please include your country code
电话 * 请填上国家代码
Description of your condition, symptoms and consultation
(Please make it as detailed as possible)
病情、病状及会诊描述（请尽可能详细描述）
Your question / inquiry
您的问题/咨询

Following questionnaire is to assess how your voice affects your everyday life. Please rate your condition considering the last two weeks on a scale of 0-4 as described below:
0 – Never; 1 – Almost never; 2 – Sometimes; 3 – Almost always; 4 – Always

下列问卷对声音在您日常生活中的影响进行了评估。请就前两周的情况进行评级，级别为0-4：
0 – 根本不影响 1 – 有一点 2 – 有时候 3 – 经常 4 – 一直

Q1. My voice makes it difficult for people to hear me.
问题1．我的声音几乎听不到。
Q2. People have difficulty understanding me in a noisy room.
问题2．说话时气急。
Q3. People ask,“What's wrong with your voice?”
问题3．我的声音在嘈杂的房间内特别难听见。
Q4. I feel as though I have to strain to produce voice.
问题4．我的声音不稳定。
Q5. My voice difficulties restrict my personal and social life.
问题5．我在屋里打电话给家人的时候，他们好像听的特别吃力。
Q6. The clarity of my voice is unpredictable.
问题6．因为我的声音问题，我一般不打电话。
Q7. I feel left out of conversations because of my voice.
问题7．因为我的声音问题，一跟人说话我就紧张。
Q8. My voice problem causes me to lose income.
问题8．因为我的声音问题，我都避免群聊。
Q9. My voice problem upsets me.
问题9．我能感觉到我的声音给别人带来的挫败感。
Q10. My voice makes me feel handicapped.
问题10．有人问过我“你的声音怎么了？

Have you tried botox injection treatments?
有试过肉毒素治疗吗？
Is your voice tremulous?
声音会颤抖吗？
Is your voice strangulated?
声音有窒息感吗？
Have you consulted with a doctor?
咨询过医生吗？
⇒If yes, what was the diagnosis?
如果有，诊断结果是什么？
内收性痉挛性发音障碍 (Adductor Spasmodic Dysphonia)
外展性痉挛性发音障碍 (Abductor Spasmodic Dysphonia)
混合型痉挛性发音障碍 (Mixed Type Spasmodic Dysphonia)
我不知道 (I do not know)
Click does not send the form yet.

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