Dysarthria Quality of Life Questionnaire
Please answer the following questions to help us understand how dysarthria affects your daily life and well-being.
Full Name
*
First Name
Last Name
Age
*
Email Address
example@example.com
How long have you experienced speech difficulties due to dysarthria?
*
Please Select
Less than 6 months
6 months to 1 year
1-3 years
More than 3 years
Please rate how much dysarthria has affected each of the following areas in your life.
*
Rows
Not at all
A little
Moderately
Quite a bit
Extremely
Speaking clearly
1
2
3
4
5
Being understood by others
6
7
8
9
10
Participating in conversations
11
12
13
14
15
Social interactions
16
17
18
19
20
Emotional well-being
21
22
23
24
25
Self-confidence
26
27
28
29
30
How often do you avoid social situations because of your speech difficulties?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your overall quality of life?
*
1
2
3
4
5
Do you currently receive any therapy or treatment for dysarthria?
*
Yes
No
If yes, please specify the type of therapy or treatment you are receiving.
What are the biggest challenges you face due to dysarthria?
Is there anything else you would like to share about your experience with dysarthria?
Submit Questionnaire
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