Voice Case History Form - University of Central Florida

Communication Disorders ClinicVoice Case HistoryName:__________________________________________Address:_________________________________________________________________________________City State ZipDate:___________________Phone:__________________Email: __________________Date of Birth:_______________________________________Occupation:________________________________________A. State of the Problem1. When did you first notice a problem with the voice?During the last week____________________________During the last month____________________________Two months ago________________________________Three months ago_______________________________If over three months, how long______________________Describe how the voice sounded.2. Has the voice gotten better or worse since the problem began? Explain.3. What do you think caused the original problem?4. During a typical day, what times or activities make the voice better of worse?WeekendsMorningsWorkRelaxationExerciseBetter Worse N/A1

Other:_______________________________________________5. At present, how does the voice sound?B. Sources of Vocal AbuseHow often are the following characteristics exhibited? (Please note from 0 – 5)_____ Yelling_____ Constant talking_____ Loud talking_____ Vocal strain to project (acting, singing, etc.)_____ Throat clearing_____ Coughing_____ Shallow breathing_____ Talk in a pitch that is too high or too low_____ Tenses voice during work, play or exercise_____ Over-enthusiastic or excited talking_____ Make animal sounds_____ Participate in exhausting activities_____ Physically lift or strain (including use of Nautilus)_____ Do not eat a balanced meal_____ Fatigue due to little sleep_____ Work or live in a dry/arid environment_____ Cry_____ Have unresolved emotional conflicts_____ Have emotional pressures that focus on throat tension_____ SmokeC. Medical History1. Please list any major illnesses (past or present).2. Please check, if applicable.Heart attack _____ __________Surgery _____ __________Stroke _____ __________Other _____ __________3. Please list any medications that are currently being taken.4. Have you ever been diagnosed with a voice problem?2

Yes_______No _______Date diagnosed_____________ By whom__________5. What was the condition of the vocal cords?DateEdema (swollen vocal tissue) ____________________________________Modules _____________________________________________________Granulomas __________________________________________________Normal ______________________________________________________Contact Ulcers ________________________________________________Carcinoma ___________________________________________________Other (list) ___________________________________________________6. Has the problem ever been treated? Yes_______ No _______If yes,By whom__________________________Dates:_____________________________7. Why type of treatment was administered? (i.e., surgery, therapy, medication).8. What was the outcome of treatment?Completed by: _____________________________(Print)Signature: _________________________________Date: _____________________________________3

COMMUNICATION DISORDERS CLINICAUTHORIZATION TO VIDEO TAPE, AUDIO TAPE, PHOTOGRAPHAND/OR OBSERVEThe University of Central Florida’s Communication Disorders Program, in addition to providingservices to the Central Florida community, functions as a training clinic for graduate students inthe Communication Disorders Program. The Florida Alliance for Assistive Services andTechnology (FAAST) also provides similar training and supervision in conjunction with theUniversity Communication Disorders program. Because of this, you may encounter certainsituations in the clinic that you might not be exposed to in another treatment setting.In order for the student clinician to receive thorough supervision, it may be necessary for theclinician to tape (Audiotape and Videotape) the sessions. In addition, there is a one-way mirrorin each therapy room, and an observation room adjoining. From time to time, the studentclinician’s session may be observed by the supervisor or by other student clinicians. At times,video and audio tape(s) may be used for educational purposes.A fully qualified professional supervises each client’s program at the Clinic. Graduate Studentsmay be assigned to work with certain clients. A qualified faculty member, however, will beresponsible for the professional services. This professional will supervise, counsel and direct theclinical activities.In hereby authorize clinical personnel from the [ ] Communication Disorders Clinic and/or [ ]FAAST to video tape, audio tape, photograph, and/or observe clinical sessions for.(Client’s name)DateSignature of ClientSignature of Parent/Guardian4

COMMUNICATION DISORDERS CLINICPERMISSION TO OBTAIN INFORMATIONI herby grant the Communication Disorders Clinic of the University of Central Florida andFlorida Alliance for Assistive Services and Technology (FAAST) to request information from therecords of:Client’s name: ____________________________________DOB: ___________________________________________Agency:Name: Address: Phone Number:1.___________________________________________________________________________________________________________________________________________2.______________________________________________________________________________________________________________________________________________3.______________________________________________________________________________________________________________________________________________4._______________________________________________________________________________________________________________________________________________________________________Date_______________________________Signature of Client_______________________________Signature of Parent/Guardian5

COMMUNICATION DISORDERS CLINICPERMISSION TO RELEASE INFORMATIONI hereby grant the Communication Disorders Clinic of the University of Central Floridapermission to release information from the records ofto the agencies listed below.(Client’s name)Send to:FAAST, Florida Alliance for Assistive Services and Technology325 John Knox Road, Building 400, Suite 402 · Tallahassee, Florida 32303Solely for the purposes of evaluating the services provided by the FAAST RegionalDemonstration Center(Parent/Guardian initial here)Send to:Name: Address: Phone Number:__________________________________________________________________________DateSignature of ClientSignature of Parent/Guardian6

PATIENT CONSENT TO THE USE AND DISCLOSURE OF HEALTHINFORMATION FOR TREATMENT, PAYMENT OR HEALTHCAREOPERATIONSI understand that as part of my healthcare, this organization originates and maintains health records describing myhealth history, symptoms, examination and test results, diagnoses, treatment and any plans for future care ortreatment. I understand that this information serves as:• A basis for planning my care and treatment• A means of communication among the many health professional who contribute to my care• A source of information for applying my diagnosis and surgical information to my bill• A means by which a third-party payer can verify that services billed were actually provided• And a tool for routine healthcare operations such as assessing quality and reviewing the competence ofhealthcare professionalsI understand and have been provided with a Notice of Information Practices that provides a more completedescription of information uses and disclosures. I understand that I have the right to review the notice prior tosigning this consent. I understand that the organization reserves the right to change their notice and practices andprior to implementation will post information of this change. I understand that I have the right to request restrictionsas to how my health information may be used or disclosed to carry out treatment, payment or healthcare operationsand that the organization is not required to agree to the restrictions requested. I understand that I may revoke thisconsent in writing, except to the extent that the organization has already taken action in reliance thereon.I authorize UCF Communication Disorders Clinic to use an automated telephone system and/or email and to use myname, address and phone number; the name of my scheduled treating physician; and the time of my scheduledappointment(s), for the limited purpose of contacting me to notify me of a pending appointment or other healthcarerelatedcommunication. I also authorize Communication Disorders Clinic to disclose to third parties who answer myphone limited protected health information regarding pending appointments, and to leave a reminder message on myvoicemail system or answering machine.______________________________________________Signature of Patient or Personal Representative____________________Date______________________________________________Printed Name of Patient or Personal Representative7

COMMUNICATION DISORDERS CLINICDRIVING DIRECTIONSThe University of Central Florida’s Communication Disorders Clinic is located in the CentralFlorida Research Park in the Research Pavilion, Building 12424, Suite 155.From Winter ParkTake University Boulevard east to Alafaya Trail, then right (south) to Research Parkway. Turnleft (east) at Bank of America, entering Central Florida Research Park. After proceeding throughthe first traffic light, the Research Pavilion will be the third building on the right.From OrlandoTake Colonial Drive (State Road 50) east to Alafaya Trail. Turn left (north) onto Alafaya Trail.At the third traffic light (Bank of America’s on the corner), turn right (east) on ResearchParkway, entering Central Florida Research Park. After proceeding through the first traffic light,the Research Pavilion will be the third building on your right.From OrlandoTake the East-West Expressway east. Do not exit to the left where there is a sign indicating thatyou should go left to UCF but continue on the expressway until you reach the Alafaya Trail exit.After exiting, turn left (north) on Alafaya Trail. After crossing Colonial Drive (State Road 50),proceed to the third traffic light (Bank of America’s on the corner), turn right (east) on ResearchParkway, entering Central Florida Research Park. After proceeding through the first traffic light,the Research Pavilion will be the third building on your right.Please feel free to contact the clinic if you are coming from a location that the above directionsdo not cover. Our telephone number is (407) 882-0468.If you would prefer to use Map Quest for directions, our address is 12424 Research Parkway,Orlando, FL 328268

Communication Disorders ClinicService Fees for Evaluation & TreatmentSpeech/Language Pathology Evaluations FeeSpeech and Language Evaluation (child) $200.00Stuttering Evaluation $200.00Voice Evaluation w/ laryngeal exam $750.00Voice Evaluation w/ acoustic exam only $200.00Reading Evaluation (includes oral language exam) 450.00Speech and Language Evaluation (adult) $250.00Assistive/Augmentative Device Evaluation $750.00(FAAST)Audiology EvaluationsFeeAuditory Processing Evaluation $190.00Hearing evaluation (basic) $75.00Hearing evaluation (extended) $120.00Earmolds/Earplugs$55.00 and upTypes of Therapy OfferedFeeFluency/Stuttering *Aural Rehabilitation *Auditory Processing *Aphasia Therapy *Voice Therapy *Preschool Speech (Articulation) & Language *School-Age Speech (Articulation) & Language *Adult Speech (Articulation) & Language *Dysarthria *Lee Silverman Voice Therapy (LSVT) *Augmentative and Alternative Communication (AAC) *Reading & Writing *Accent Reduction *Traumatic Brain Injury Program *Intensive Aphasia Program *Brain Fitness (Dementia Program) **Fees for therapy sessions are determined on a sliding scale based on annual income and numberof family members. Please visit the fees chart on our website.9