Speech Difficulty Questionnaire Form
Please complete this Speech Difficulty Questionnaire Form to help us understand your speech experiences. Your responses will remain confidential and are used solely for assessment purposes.
How often do you experience difficulty speaking or pronouncing words?
*
Never
Rarely
Sometimes
Often
Always
Please rate the overall severity of your speech difficulty.
*
1
2
3
4
5
In which situations do you notice speech difficulties? (Select all that apply)
*
Speaking with family
Speaking with friends
Speaking at work or school
Talking on the phone
Public speaking
Other
How much do speech difficulties impact your daily life?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Do you avoid certain situations because of your speech difficulties?
*
Never
Rarely
Sometimes
Often
Always
Please indicate the types of speech difficulties you experience.
*
Stuttering
Slurred speech
Difficulty finding words
Repeating words or sounds
Difficulty starting words
Other
How long have you been experiencing speech difficulties?
*
Less than 1 month
1 to 6 months
6 months to 1 year
More than 1 year
Please rate your confidence when speaking in different situations.
*
Rows
Not confident
Somewhat confident
Confident
Very confident
With family
1
2
3
4
With friends
5
6
7
8
At work or school
9
10
11
12
In public
13
14
15
16
Have you previously received any support or therapy for speech difficulties?
*
Yes
No
If you wish, please describe any other challenges or concerns related to your speech.
Submit
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