Search:
Patients & Visitors
Services
About Us
News & Events
Work With Us
Education & Research
Contact & Find Us
GPs & Clinicians' Area
Telephone:
020 8672 1255
Privacy and Cookies
Find Us
Contact Us
Search:
Go to Homepage
Skip to content
Patients & Visitors
Services
About Us
News & Events
Work With Us
Education & Research
Contact & Find Us
GPs & Clinicians' Area
Home
>
Services
> TEST QUESTIONNAIRES
Patients & Visitors
Services
TEST QUESTIONNAIRES
About Us
News & Events
Work With Us
Education & Research
Contact & Find Us
GPs & Clinicians' Area
TEST QUESTIONNAIRES
Sub-menu
Patients & Visitors
Services
TEST QUESTIONNAIRES
About Us
News & Events
Work With Us
Education & Research
Contact & Find Us
GPs & Clinicians' Area
On this page:
Main content
Anxiety (GAD-7)
Name
*
First
Last
Date
*
DD slash MM slash YYYY
Date of Birth
*
Clinician
*
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge
*
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying
*
Not at all
Several days
More than half the days
Nearly every day
Worrying too much about different things
*
Not at all
Several days
More than half the days
Nearly every day
Trouble relaxing
*
Not at all
Several days
More than half the days
Nearly every day
Being so restless that it is hard to sit still
*
Not at all
Several days
More than half the days
Nearly every day
Becoming easily annoyed or irritable
*
Not at all
Several days
More than half the days
Nearly every day
Feeling afraid as if something awful might happen
*
Not at all
Several days
More than half the days
Nearly every day
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
*
Not difficult at all
Somewhat difficult
Very difficult
Extremely difficult
Δ
Paediatric Voice Handicap Index
Name
*
First
Last
Date
*
DD slash MM slash YYYY
Date of Birth
*
Clinician
*
Instructions
These are statements that many people have used to describe their voices and the effects of their voices on their lives. Circle the response that indicated how frequently you have the same experience.
I would rate my/my child’s talkativeness as the following
*
1 - Quiet listener
2
3
4 - Average talker
5
6
7 - Extremely talkative
My child’s voice makes it difficult for people to hear him/her
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
People have difficulty understanding my child in a noisy room
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
At home, we have difficulty hearing my child when he/she calls through the house
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child tends to avoid communicating because of his/her voice
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child speaks with friends, neighbours, or relatives less often because of his/her voice
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
People ask my child to repeat him/herself when speaking face-to-face
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child’s voice difficulties restrict personal, educational and social activities
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child runs out of air when talking
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
The sound of my child’s voice changes throughout the day
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
People ask, ‘What’s wrong with your child’s voice?’
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child’s voice sounds dry, raspy, and/or hoarse
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
The quality of my child’s voice is unpredictable
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child uses a great deal of effort to speak (e.g. straining)
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child’s voice is worse in the evening
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child’s voice ‘gives out’ when speaking
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child has to yell in order for others to hear him/her
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child appears tense when talking to others because of his or her voice
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
People seem irritated with my child’s voice
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
I find other people don’t understand my child’s voice problem
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child is frustrated with his/her voice problem
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child is less outgoing because of his/her voice problem
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child is annoyed when people ask him/her to repeat
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
My child is embarrassed when people ask him/her to repeat
*
0 - Never
1 - Almost Never
2 - Sometimes
3 - Almost always
4 - Always
Δ
Singing Voice Handicap Index-10 (SVHI-10)
Name
*
First
Last
Date
*
DD slash MM slash YYYY
Date of Birth
*
Clinician
*
Status of therapy
*
Pre-therapy
Post-therapy
If you are a PERFORMER, please answer each of the following questions, even if your answer is “never” or “no problem”.
SVHI-10: These are statements that many people have used to describe their singing voices and the effects of their singing on their lives. Please indicate how frequently you had the same experience within the past month
It takes a lot of effort to sing
*
Never
Almost never
Sometimes
Almost always
Always
I am unsure of what will come out when I sing
*
Never
Almost never
Sometimes
Almost always
Always
My voice “gives out” on me while I am singing
*
Never
Almost never
Sometimes
Almost always
Always
My singing voice upsets me
*
Never
Almost never
Sometimes
Almost always
Always
I have no confidence in my singing voice
*
Never
Almost never
Sometimes
Almost always
Always
I have trouble making my voice do what I want it to do
*
Never
Almost never
Sometimes
Almost always
Always
I have to “push it” to produce my voice when singing
*
Never
Almost never
Sometimes
Almost always
Always
My singing voice tires easily
*
Never
Almost never
Sometimes
Almost always
Always
I feel something is missing in my life because of my inability to sing
*
Never
Almost never
Sometimes
Almost always
Always
I am unable to use my “high voice”
*
Never
Almost never
Sometimes
Almost always
Always
Δ
Hospital Anxiety and Depression Scale (HADS)
Name
*
First
Last
Date
*
MM slash DD slash YYYY
Date of birth
*
Clinicians
*
Tick the box beside the reply that is closest to how you have been feeling in the past week. Don’t take too long over you replies: your immediate is best.
I feel tense or 'wound up':
*
Not at all
From time to time, occasionally
A lot of the time
Most of the time
I still enjoy the things I used to enjoy:
*
Definitely as much
Not quite so much
Only a little
Hardly at all
I get a sort of frightened feeling as if something awful is about to happen:
*
Very definitely and quite badly
Yes, but not too badly
A little, but it doesn't worry me
Not at all
I can laugh and see the funny side of things:
*
As much as I always could
Not quite so much now
Definitely not so much now
Not at all
Worrying thoughts go through my mind:
*
A great deal of the time
A lot of the time
From time to time, but not too often
Only occasionally
I feel cheerful:
*
Not at all
Not often
Sometimes
Most of the time
I can sit at ease and feel relaxed:
*
Definitely
Usually
Not Often
Not at all
I feel as if I am slowed down:
*
Nearly all the time
Very often
Sometimes
Not at all
I get a sort of frightened feeling like 'butterflies' in the stomach:
*
Not at all
Occasionally
Quite Often
Very Often
I have lost interest in my appearance:
*
Definitely
I don't take as much care as I should
I may not take quite as much care
I take just as much care as ever
I feel restless as I have to be on the move:
*
Very much indeed
Quite a lot
Not very much
Not at all
I look forward with enjoyment to things:
*
As much as I ever did
Rather less than I used to
Definitely less than I used to
Hardly at all
I get sudden feelings of panic:
*
Very often indeed
Quite often
Not very often
Not at all
I can enjoy a good book or radio or TV program:
*
Often
Sometimes
Not often
Very seldom
Δ
Patient Health Questionnaire (PHQ-9)
Name
*
First
Last
Date
*
DD slash MM slash YYYY
Date of birth
*
Clinician
*
Over the last two weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things?
*
None
Mild
Moderate
Moderately Severe
Severe
Feeling down, depressed, or hopeless?
*
None
Mild
Moderate
Moderately Severe
Severe
Trouble falling or staying asleep, or sleeping too much?
*
None
Mild
Moderate
Moderately Severe
Severe
Feeling tired or having little energy?
*
None
Mild
Moderate
Moderately Severe
Severe
Poor appetite or overeating?
*
None
Mild
Moderate
Moderately Severe
Severe
Feeling bad about yourself - or that you are a failure or have let yourself or your family down?
*
None
Mild
Moderate
Moderately Severe
Severe
Trouble concentrating on things, such as reading the newspaper or watching television?
*
None
Mild
Moderate
Moderately Severe
Severe
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual?
*
None
Mild
Moderate
Moderately Severe
Severe
Thoughts that you would be better off dead, or of hurting yourself in some way?
*
None
Mild
Moderate
Moderately Severe
Severe
Δ
Reflux Symptoms Index
Name
*
First
Last
Date of Birth
*
Date
*
DD slash MM slash YYYY
Within the last month, to what degree did the following problems affect you?
Hoarseness or a problem with your voice
*
0
1
2
3
4
5
Clearing of your throat
*
0
1
2
3
4
5
Excess throat mucus or postnasal drip
*
0
1
2
3
4
5
Difficulty swallowing food, liquids, or pills
*
0
1
2
3
4
5
Coughing after you eat or after lying down
*
0
1
2
3
4
5
Breathing difficulties or choking episodes
*
0
1
2
3
4
5
Troublesome or annoying cough
*
0
1
2
3
4
5
Sensation of something sticking in your throat or a lump in your throat
*
0
1
2
3
4
5
Heartburn or chest pain
*
0
1
2
3
4
5
Δ
Voice Handicap Index - 10 Self Rating From
Name
*
First
Last
Date of Birth
*
Date
*
DD slash MM slash YYYY
Name of Clinician
*
Status of Therapy
*
Pre-therapy
Post-therapy
Instructions
These are statements that many people have used to describe their voices and the effects of their voices on their lives. Tick the response that indicates how frequently you have the same experience.
My voice makes it difficult for people to hear me.
*
Never
Almost never
Sometimes
Almost always
Always
I run out of air when I talk.
*
Never
Almost never
Sometimes
Almost always
Always
People have difficulty understanding me in a noisy room.
*
Never
Almost never
Sometimes
Almost always
Always
The sound of my voice varies throughout the day.
*
Never
Almost never
Sometimes
Almost always
Always
My family has difficulty hearing me when I call them throughout the house.
*
Never
Almost never
Sometimes
Almost always
Always
I use the phone less often than I would like.
*
Never
Almost never
Sometimes
Almost always
Always
I tend to avoid groups of people because of my voice.
*
Never
Almost never
Sometimes
Almost always
Always
People seem irritated with my voice.
*
Never
Almost never
Sometimes
Almost always
Always
People ask, “What’s wrong with your voice ?”
*
Never
Almost never
Sometimes
Almost always
Always
Δ
Our Values
Patients and Visitors
Work With Us
About Us
GP and Clinician Area
Go to Homepage
Go to Homepage
