Voice Tremor Assessment Form
Please complete this form to help assess your voice tremor symptoms and their impact.
Patient Full Name
*
First Name
Last Name
Email Address
*
example@example.com
How long have you been experiencing voice tremor symptoms?
*
Describe your voice tremor symptoms (e.g., when do they occur, what triggers them, associated sensations)
*
Please rate the severity of your voice tremor over the past week
*
No tremor
0
1
2
3
4
5
6
7
8
9
Severe tremor
10
0 is No tremor, 10 is Severe tremor
How much does your voice tremor impact your daily activities?
*
Not at all
A little
Moderately
Quite a bit
Extremely
Upload a short voice sample (optional, if requested by your clinician)
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