ANAMNESE DE DISFONIA

Data: _________________________________________
Nome: __________________________________________________________________
Data de Nasc: ________________________________
End: ____________________________________________________________________
Telefone: _____________________________________
Profisso:__________________________________________________

Motivo da Consulta:
Antecedentes:
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" Afeces vocais anteriores:
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" Distrbios respiratrios:

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" Distrbios faringeanos:

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" Distrbios laringeanos:

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" Distrbios bucais:

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" Audio:
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" Guarda repouso vocal?

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Distrbios Neuro-vegetativos:
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" Alteraes Gastro-intestinais?

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" Taquicardia/bradicardia?
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Distrbios Hormonais:
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" Afeco endcrina?

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" Alterao de peso?
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" Obesidade?
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" Emagrecimento?
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" Alterao de apetite?

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" Tem filhos?

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Mulher:

" Alteraes Menstruais?

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" H modificao da voz nos perodos menstruais?

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" Abortos?
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" Partos?
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" Contraceptivos?
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Distrbios Emocionais:
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" Emoes repercutem na voz?

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Alergias:
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" Alrgico?
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" Alimentos ou outras substncias que interfiram na voz?

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" Intolerncia a frio ou calor?

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" Obstruo nasal brusca?

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Distrbio Vocal:
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" Incio:
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" Brusco ou progressivo?

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" Dificuldade para falar normalmente?

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" Fala Muito?

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" Fala Alto?

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" A voz cansa rpido?

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" Perodos de melhora ou piora?

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" Impresso da sua voz?

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" Dificuldade para canto?

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" Pratica esportes?

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" Voz falada melhor que a cantada?

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" Dificuldade para mastigar ou engolir?

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" Fala muito no trabalho?

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" Fala em ambiente ruidoso?
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" Fala muito ao telefone?

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" Grita?
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" Pessoas surdas em seu convvio?

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" Ar-condicionado?
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" Bebidas geladas?

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" Fuma?
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" Bebida alcolica com frequncia?

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" Sono tranquilo?

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" Como se sente?

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Resultado do exame ORL:
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Tratamentos anteriores:
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Fonte: http://www.profala.com/frameset.htm

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