Speech Fluency (Stuttering) Assessment Questionnaire Form
Please answer the following questions to help assess patterns and characteristics of speech fluency and stuttering. Your responses will provide valuable insights for evaluation.
How often do you notice disruptions (stuttering) in your speech?
*
Never
Rarely
Sometimes
Often
Always
In which situations do you experience the most difficulty with speech fluency?
*
Speaking with strangers
Speaking on the phone
Speaking in groups
Public speaking
Reading aloud
No particular situation
Other
Rate the overall severity of your stuttering.
*
No stuttering
1
2
3
4
5
6
7
8
9
Very severe
10
1 is No stuttering, 10 is Very severe
How much does stuttering interfere with your daily communication?
*
Not at all
1
2
3
4
5
6
7
8
9
Extremely
10
1 is Not at all, 10 is Extremely
Which types of disfluencies do you most frequently experience?
*
Repetitions (e.g., b-b-boy)
Prolongations (e.g., sssssun)
Blocks (e.g., ...cat)
Interjections (e.g., um, uh)
Other
How do you feel about your speech fluency?
*
Very comfortable
Somewhat comfortable
Neutral
Somewhat uncomfortable
Very uncomfortable
How often do you use strategies or techniques to manage stuttering?
*
Never
Rarely
Sometimes
Often
Always
Indicate how frequently you experience the following behaviors when you stutter.
*
Rows
Never
Rarely
Sometimes
Often
Always
Eye blinking
1
2
3
4
5
Facial tension
6
7
8
9
10
Hand or foot movement
11
12
13
14
15
Head movement
16
17
18
19
20
How would you describe the impact of stuttering on your social interactions?
*
No impact
Minor impact
Moderate impact
Significant impact
Severe impact
Please share any additional comments about your experience with speech fluency or stuttering.
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