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Menu
HOME
SERVICES
DOCTORS
INFORMATION
FAQ
Health Professionals
Patients
Publications
Webinars & Seminars
Blog
FORMS & REFERRALS
Appointment Request Form
Lung Function Request Form
Sleep Study Request Form
Medical Review Referral Form
Patient Registration Form
Medical History
Epworth Sleepiness Scale
Stop-Bang Questionnaire
Asthma Control Questionnaire
Vocal Cord Dysfunction Questionnaire
CONTACT US
Online Appointment
Online Appointment
online Appointment
Forms
Vocal Cord Dysfunction
Questionnaire (VCD-Q)
FORMS
Fill all required fields (★) to submit the form.
Patient details:
Full Name:
(Required)
★ Title
Mr
Mrs
Ms
Miss
Other
Prefix
First
Last
Preferred name:
Date of birth:
(Required)
DD slash MM slash YYYY
Mobile Number
(Required)
Home Phone:
Address:
Email address
(Required)
Height:
(Required)
Weight:
(Required)
• This is a questionnaire developed to help monitor symptoms in patients with a diagnosis of Vocal cord Dysfunction, or PVFM. • These are statements many people have used to describe their breathing symptoms and the effects of these symptoms on their lives. • Please circle the response that indicates how much you agree with each statement
1. My Symptoms are confined to my throat/upper chest.
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
2. I feel like I can’t get breath past a certain point in my throat/upper chest because of restriction
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
3. My breathlessness is usually worse when breathing in
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
4. My attacks typically come on very suddenly
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
5. I feel that there is something in my throat that I can’t clear
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
6. My attacks are associated with changes in my voice
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
7. My breathing can be noisy during attacks
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
8. I’m aware of other specific triggers that cause attacks
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
9. My symptoms are associated with an ache or itch in my throat
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
10. I am frustrated that my symptoms have not been understood correctly
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
11.0 I am unable to tolerate any light pressure around the neck – e.g. tight clothes or bending the neck
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
12.The attacks impact on my social life
(Required)
1 : Strongly Disagree
2 : Disagree
3 : Neither Agree or Disagree
4 : Agree
5 : Strongly Agree
Scoring:
Confirm:
(Required)
I confirm that the above information is complete and correct.
(Required)
