AVALIAÇÃO GLOBAL DA VOZ

BEHLAU E PONTES, 1989

ANAMNESE

1- IDENTIFICAÇÃO PESSOAL

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Idade_____________________ Nascimento ____ / ____ /____ Local__________________________
Nacionalidade______________________________ Estado civil______________________________
Profissão___________________________________________________________________________
Período de trabalho___________________________________________________________________
Outra atividade______________________________________________________________________
Endereço____________________________________________Telefones_______________________
Encaminhado por____________________________________________________________________
Médico____________________________________________________________________________

2- QUEIXA E DURAÇÃO
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3- HISTÓRIA PREGRESSA DA DISFONIA

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4- INVESTIGAÇÃO COMPLEMENTAR
a)Distúrbios alérgicos, faringicos, bucais, nasais, ontológicos, pulmonares, digestivos, hormonais e neuro-
vegetativos.
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b)Antecedentes pessoais
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c)Antecedentes familiares
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d)Impressão sobre a própria voz

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e)Impressão de outros sobre sua voz

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5- TRATAMENTO JÁ EFETUADO PARA A DISFONIA

Medicamentoso, fonoterapico, cirúrgico, psicoterápico, outros
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6- OUTROS DADOS E OBSERVAÇÕES

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Motivação para a terapia e para seguir a conduta em casa

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