Vocal Health Triage Form

Vocal Health Triage Form
Please answer as honestly as possible. Indicate NA if not applicable.

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PLEASE NOTE

- Line will NOT be providing you with a diagnosis. She will be triaging your voice and your health so she can give you recommendations such as specific vocal exercises and therapeutic strategies, warm up regime tailored to your vocal needs, general health advice, change of lifestyle or habit, making an appointment to see a vocal coach, GP or an ENT/Laryngologist, nutritionist or other healthcare specialist.

- You will also be provided with references and resources such as books, research literature, websites and YouTube videos that she thinks might help you. Give Line as much information as you can so she can give you the best solutions appropriate to you and your vocal needs.

- All your personal and health information is kept confidential as per GDPR regulations. Check the Privacy Notice at the end of the form.

- There may be times when Line may need to discuss your case with another health or related professional in order to gain the information she knows will help you. In this instance your name will not be revealed unless you request it to be. She cannot receive medical notes from your health practitioners unless you give them express permission. Feel free to upload any letters, images etc that you think will help her understand your situation more deeply.
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Contact Number
Age
I am
Pronouns
I am a (Tick all that apply)

Professional/Semi-Pro performerAmateur performerSingerSinging teacherProfessional dancer who singsAcrobat who singsProfessional actor who singsChoir DirectorInstrumentalist who singsMDSchool/college teacher (singing related)School/college teacher(non singing)Professional voice user (e.g. public speaker, presenter)Business professionalOther
Mother tongue
Working language/s (singing/speaking)
Describe your usual work (Tick all that apply)

Artist (e.g.singer/songwriter)Function singerSession singerMusical Theatre performerSinging TeacherTribute singerBacking VocalistCircusChoir DirectorChoir/Chorus singerCruise-boatsDisneyPart time guest speakerFull time guest speakerPart time classroom teacher/lecturerFull time classroom teacher/lecturerSeminars, public presentations etcOther
Years of work related voice use
Section 1 (Singing)

Singing related. Speaking related go to section 2
Usual singing style e.g. pop, gospel, rock, MT etc
Other singing styles you sing regularly
Usual vocal range (this is your working range e.g. G3 to G5 where C4 = middle C)
What is your gigging/performance/working history? Include age you started, types of gigs/performance, general career path.
Performance environment (Tick all that apply)

Solo -self accompanied/backing or one accompaniestBand -acousticBand -electronicPAs/DJVocal groupBig band/orchestral singingMusical TheatreSession singer - studioSession singer - backing vocalsChoir -classicalChoir - gospelChoir jazz/pop/rockRegular songwriting sessions (solo or collaborative)N/AOther
Do you play an instrument when you sing or perform? If so what?
Describe your usual sound system set up including mic, PA, IEMs, if you have a sound engineer.
Do you dance/do acrobatics/other movement whilst you sing? If yes please describe further.
Vocal training history (include years of study and the technique)
Describe your usual vocal exercise routine include types of exercises, frequency and duration?
Do you work outside of singing/perfroming? If so what is the job and how many hours do you do?
Section 2 (All)

For all clients
What is your usual workload - includes gigs, rehearsals, recording and any sessions where you sing or use your voice professionally?

Not working1 day or less per month1-5 times per month5-15 times per month15-25 times per month>25 times per monthOther
When you use your voice professionally what is your average daily workload?

1-3 hours4-8 hours> 8 hoursN/AOther
Do you consider yourself or have you been told you are a talkative person?
Teacher/speakers: Work environment

Classroom: Nursery - 11 year oldsClassroom: 12- 18 year oldsCollege/university levelCorporate speaking gigsConferencesSmall groups/workshopsAfter dinner speakingOnline webinars/workshops/courseOther
Do you study with a singing teacher or vocal coach?

Yes - currentYes - pastNeverN/A
Do you have a warmup/cool down regime when performing/rehearsing/recording/teaching/speaking or songwriting? If yes please describe.
Please add 1-3 links to examples of your speaking voice or singing (Youtube/Vimeo/Soundcloud). If possible please include examples of your voice when it's functioning well and with your issue.
On a scale of 0 to 10 how important is having a healthy, optimum working voice to you?

0

1

2

3

4

5

6

7

8

9

10

0 is Not important, 10 is Vital

Voice Assessment (please indicate your CURRENT level of severity)

	0 no symptoms	1 occasionally	2 often	3 always	N/A
Difficulty in or loss of lower range
Difficulty in or loss of higher range
Unable to sing/speak loudly
Unable to sing/speak quietly
Difficulty with or unable to sustain long notes
Pitch problems - sharp (ie above the note)
Pitch problems - flat (ie below the note)
Need to "push" voice when singing higher notes
Singing is effortful
Speaking is effortful
Change in speaking voice e.g. loss of strength, hoarse, rattle, breathy
Unable to control pitch
Voice cracks/flips when speaking
Unable to sing through vocal range smoothly eg. voice cracks or flips
Presence of vocal fry (rattle)
Difficulty with breath management
Vocal fatigue - feels tired or aches after singing
Hoarseness after singing or speaking a lot
Loss of voice after singing or speaking a lot
Breathy tone -singing and/or speaking
Constantly feeling breathless/running out of breath
Voice suddenly disappears or splits into more than one note as you sing higher
Constantly need to clear throat
Voice sounds deeper in the morning
Pain or burning sensation in throat
Pain or sensitivity around the larynx
Increase in mucous/phlegm production
Brushing teeth causes gag reflex
Constant dry mouth/throat
Contant post nasal drip
Symptoms come and go, day to day
Changes in voice have lasted longer that 2 weeks
Other (please describe below)

Other
Please describe your issue further. e.g. when it occurs, how long it has been a problem for, other symptoms or possible causes.
On a scale of 0 to 10 where would you score your current vocal health issue level

0

1

2

3

4

5

6

7

8

9

10

0 is Not an issue, 10 is It's the worst it could be
Have you currently had to stop performing/working due to your health issues?

NoYes, totally stoppedReduced work loadN/A
if you have you seen an Ear Nose and Throat specialist/ Laryngologist please indicate date, what was diagnosed, the treatment and last appointment.
Are you having/have you had Speech Therapy?

NoYes - currentYes - past
Are you having/have you been working with a Vocal Rehabilitation Coach?

NoYes - currentYes - past

Have you had or do you have any of the following?

	Medical Diagnosis	Past History	Family History	Self-diagnosis	Current Issue
Allergies (Please specify on Comment box)
Hay fever
Rhinitis
Respiratory conditions e.g. Asthma, COPD, emphysema, Covid-19, Long Covid
Gastric reflux
Thyroid issues
Diabetes
Hormonal issues (Endometriosis, peri menopausal, menopausal, PMS)
History of vocal issues such as vocal nodules, polyps, haemorrhage, cyst etc
Tongue Tie
Speech impediment
Hypermobility (joint laxity, EDS or Marfans)
Spinal deforminty (scoliosis, kyphosis)
Cold sores
Cystic Fibrosis
Chronic Fatigue/ME
Anxiety/panic attacks
Depression
Psychiatric disorder
Rheumatoid Arthritis
Osteoarthritis
Parkinson's
Other neurological disorders
Cancer (Please explain further in Comment box - origin and treatment)
Fibromyalgia
Other medical condition (please explain further in Comment box)
Brain injury
Other (please describe below)

Other
History of motor vehicle accident? (include year and any injuries sustained)
History of head injury? (include year)
History of any other significant injury eg skiing or bike accident? (include year and in juries sustained)
History of surgery? (include type and year and any injuries sustained)
Any chronic pain issues?
Any joint/skeletal/spine issues? e.g. sprains, fractures, deterioration
Do you have been diagnosed with any learning difficulties? e.g. dyslexia, on the spectrum, ADHD
Prescribed medications. (If you are on oral contraceptive please indicate name.)
Over the counter medications.
Upload any images or letters from doctors you feel may be relevant. Files larger than 100MB will need to be sent via Dropbox or WeSend or similar to info@linehilton.com

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Are you a smoker?

NoYesOccasionalEx smoker < 6 yearsEx Smoker > 6 years

Alcohol consumption

	Never	Occasional	Often	Always
Weekends
Work days

Do you use illicit drugs? (Please note this will not be divulged to anyone it is purely for Line to get the complete picture.)

Never (skip next question)OccasionalRegularlyType option 4
Which drugs in particular? (Tick all that apply)

CannabisCocaineHeroinMethamphetamineEcstasyCrack cocaineInhalantsHallucinogensOther
Do you maintain a fitness regime? If so please describe:
Hobbies?
Are there any other activities you do that you want to list?
Do you follow a specific diet/nutritional plan? If yes please explain further.
What are your normal eating times?
What are your eating times when working?
Approx daily water consumption (in litres)
Describe your usual sleeping habits and patterns.
Are you experiencing any sleep issues currently?
How is your home life? (If you have challenges then give a general summary of any particular difficulties eg relationship or living hardships)
On a scale of 0 to 10 where would you score your current level of stress

0

1

2

3

4

5

6

7

8

9

10

0 is No stress, 10 is I'm about to explode
How do you feel about your voice?
What is your no. 1 priority with your voice right now?
What do you think your biggest obstacle is to vocal recovery?
Please add any other comments you feel will help Line in understanding your situation and challenges.
By signing your full name below, you explicitly consent to us processing the personal data you have included in this form in accordance with our Privacy Policy as set out below.

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Link to Line Hilton's Privacy Policy and Medical Disclaimer
- When you book your first session you be added to the Line Hilton Client mailing list in order for us to communicate things such as booking information, payment instructions and follow up correspondence.
- We may also from time to time send you details of services, updates and offers that we feel may interest you, including promotional offers, up and coming events and partner promotions by email. You may opt out of receiving such communications at any time:
Please tick:

I understand I will be added to Line Hilton booking and admin emailsI'd also like news, updates, offers from Line Hilton
Cancellation policy. If you miss your appointment, or cancel with less than 24 hours notice, you will be charged the full price of your appointment. More info: https://www.linehilton.com/payment-and-cancellation-policy/

I understand and agree to Line Hilton's cancellation policyI do not agree to Line Hilton's cancellation policy (Please do not complete your booking)

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2 hour Vocal Health Assessment: Includes consultation, voice assessment, health and vocal advice and recommendations. This covers the 2-hour session + 15 min follow up. And includes history review, voice assessment, warm-up exercises recommendations, plus recommendations and resources to help your vocal recovery.

£190.00

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Vocal Health Triage Form

Section 1 (Singing)

Section 2 (All)

LINE'S NOTES AND FOLLOW UP RECOMMENDATIONS