Items with asterisk * are mandatory. Please be sure you fill out these items.
Date of birth*
Phone Number
* please include your country code
Description of your condition, symptoms and consultation
(Please make it as detailed as possible)
Your question / inquiry

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

Q1. My voice makes it difficult for people to hear me.
Q2. People have difficulty understanding me in a noisy room.
Q3. People ask,“What's wrong with your voice?”
Q4. I feel as though I have to strain to produce voice.
Q5. My voice difficulties restrict my personal and social life.
Q6. The clarity of my voice is unpredictable.
Q7. I feel left out of conversations because of my voice.
Q8. My voice problem causes me to lose income.
Q9. My voice problem upsets me.
Q10. My voice makes me feel handicapped.?

Have you tried botox injection treatments?
Is your voice tremulous?
Is your voice strangulated?
Have you consulted with a doctor?
⇒If yes, what was the diagnosis?
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