VHA History Form

VHA History Form

Please answer as honestly as possible. Indicate NA if not applicable
PLEASE NOTE
- The session last 2 hours
- 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 show her any letters, images etc that you think will help her understand your situation more deeply.
Name

First Name Last Name
Email
example@example.com
Address

Street Address

Street Address Line 2

City State

Zip Code Country
Contact Number

Area Code Phone Number
Age
I am
Pronouns
I am a (Tick all that apply)

Professional performer Semi-pro performer Amateur performer Singer Professional dancer who sings Professional actor who sings Choir Director Instrumentalist who sings MD Acrobat who sings Singing teacher School/college teacher (singing related) School/college teacher(non singing) Professional voice user (e.g. public speaker) Business professional
Mother tongue
Working language/s (singing/speaking)
Years of singing/performing/teaching/directing/professional speaking
Usual vocal 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)
Describe your usual work (Tick all that apply)

Artist (e.g.singer/songwriter) Function singer Session singer Musical Theatre performer Singing Teacher Tribute singer Backing Vocalist Circus Choir Director Choir/Chorus singer Cruise-boats Disney Part time speaker Full time speaker Part time classroom teacher/lecturer Full time classroom teacher/lecturer Business presentations and/or pitching
What is your gigging/performance/working history? Include age you started, types of gigs/performance, general career path.
What is your usual workload - includes gigs, rehearsals, recording and any sessions where you sing or speak professionally?

Not working 1 day or less per month 1-5 times per month 5-15 times per month 15-25 times per month >25 times per month
When you sing/speak professionally what is your average daily workload?

1-3 hours 4-8 hours > 8 hours N/A
Do you consider yourself or have you been told you are a talkative person?
Singers: Performance environment (Tick all that apply)

Solo -self accompanied/backing or one accompaniest Band -acoustic Band -electronic PAs/DJ Vocal group Big band/orchestral singing Musical Theatre Session singer - studio Session singer - backing vocals Choir -classical Choir - gospel Choir jazz/pop/rock Regular songwriting sessions (solo or collaborative) N/A
Teacher/speakers: Work environment

Classroom: Nursery - 11 year olds Classroom: 12- 18 year olds College/university level Corporate speaking gigs Conferences Small groups/workshops After dinner speaking
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)
Do you study with a singing teacher or vocal coach?

Yes - current Yes - past Never N/A
Describe your usual vocal exercise routine include types of exercises, frequency and duration?
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)

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.
Have you currently had to stop performing/working due to your health issues?

No Yes, totally stopped Reduced work load N/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?

No Yes - current Yes - past
Are you having/have you been working with a Vocal Rehabilitation Coach?

No Yes - current Yes - 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
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 hello@linehilton.com

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Are you a smoker?

No Yes Occasional Ex smoker < 6 years Ex 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) Occasional Regularly Type option 4
Which drugs in particular? (Tick all that apply)

Cannabis Cocaine Heroin Methamphetamine Ecstasy Crack cocaine Inhalants Hallucinogens
Singers/performers: Do you work outside of singing? If so what is the job and how many hours do you do?
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 how important is singing/professional voice use to you?

	0	1	2	3	4	5	6	7	8	9	10

0 is Not important, 10 is My reason for getting up every day!

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

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Vocal Health Assessment: Includes consultation, voice assessment, health and vocal advice and recommendations. £ 150.00

This is a 2 hour session plus follow up recommendations.

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Internet Bank transfer. You will be sent an invoice by email. Additional fees may be applied for transfers outside of the UK. Once you have paid please email info@linehilton.com to confirm payment and then book your session https://10to8.com/book/tefyjmvvlvyrlkmlzv/927633 When I book my appointment:
LINE'S NOTES AND FOLLOW UP RECOMMENDATIONS

This part of the form will be filled in by Line and sent to you after your session. If you have any questions please don't hesitate to email her: info@linehilton.com
Vocal workload (on the job)
Recommendations
Vocal workload (outside of the job)
Recommendations
Performance (posture, playing an instrument, choreography etc)
Recommendations
Sound system etc
Recommendations
Touring & Recording
Recommendations
Warmup/cool down regime
Recommendations
Vocal training & regime
Recommendations
Vocal health
Recommendations
General Health and wellbeing
Recommendations
Nutrition and hydration
Recommendations
Medical (General)
Recommendations
Medical (Voice)
Recommendations
Mindset
Recommendations
Medications and OTC
Recommendations
Smoking, alcohol and illicit drugs
General fitness
Recommendations
Hobbies
Recommendations
Obstacles
Recommendations
Top priorities
Recommendations
Resource files

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Final comments and recommendations
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