• Document: LSVT LOUD Assessment Packet Initial Interview Evaluation Protocol Stimulability Protocol Follow-up Questions Perceptual Scales
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® LSVT LOUD Assessment Packet Initial Interview Evaluation Protocol Stimulability Protocol Follow-up Questions Perceptual Scales Copyright© 2012 LSVT Global, Inc. 5- 23 This page may be reproduced for clinical use by LSVT LOUD Certified Clinicians LSVT® LOUD Initial Interview Identifying Information Name: email address: Address: City: State: Zip: Phone: Fax: Age: Date of Birth: Date and Time of Day of Initial Interview: Diagnosis/Stage: Date of Initial Diagnosis: Time of Last Park med: Time of Next Park med: Neurologist: Phone: Address: Neurosurgeon: Phone: Address: Otolaryngologist: Phone: Address: Physical Therapist: Phone: Address: Neurological and Other Medical Information What were your initial symptoms of Parkinson disease? Do you have any tremor? Yes No If yes, please describe: Do you have any other medical problems? Yes No If yes, please describe: Copyright© 2012 LSVT Global, Inc. 5- 24 This page may be reproduced for clinical use by LSVT LOUD Certified Clinicians Medication Information: Medication for Parkinson disease: Other Medications: How is it helpful? Does your Parkinson medication affect your voice or speech? Yes No If yes, please describe: Do you experience “on/off” symptoms? Yes No If yes, please describe: Do you experience any dyskinesias: Yes No If yes, please describe: Surgical Information: Have you had neurosurgery or laryngeal surgery? If yes, what procedure, when, where, by whom? Speech Symptoms: Have you ever used your voice professionally (i.e., radio, television, acting, singing, etc.)? Yes No If yes, please describe: When did you first start to notice communication symptoms (i.e., changes in your speech and/or voice) that you associate with Parkinson disease? What are your current symptoms? What is your most significant problem communicating today? How do you typically use your voice during the day? Copyright© 2012 LSVT Global, Inc. 5- 25 This page may be reproduced for clinical use by LSVT LOUD Certified Clinicians How many hours of speaking do you do in a day? Right now does your voice sound like it usually does? Do people ask you to repeat? What do you do when you want to be as easy to understand as possible? What percent of your speech do you think is intelligible (i.e., people can understand you)? Has Parkinson disease caused you to talk less? How much less? Why has Parkinson disease caused you to talk less? Do you think you run out of breath during speech? Is it difficult for you to take a deep breath? Have you noticed if your voice is monotone in pitch? Have you noticed if your speaking voice is higher or lower in pitch now compared to before you were diagnosed with Parkinson disease? Have you noticed pitch breaks in your voice? Have you noticed changes in your singing voice? Have you noticed changes in the quality of your voice? If yes, please describe the changes you have noticed in quality. (Probe patient to determine if patient thinks voice quality is hoarse, wet, breathy, rough, strained, etc.) Have you noticed changes in the steadiness of your voice? Does your voice feel fatigued at the end of the day? Have you noticed if your voice is reduced in loudness? Have you noticed any slurring or mumbling in your speech? Has the rate of your speech changed? If yes, please describe how your rate has changed. (Probe patient to determine if patient thinks rate is faster, slower, variable, etc.) Copyright© 2012 LSVT Global, Inc. 5- 26 This page may be reproduced for clinical use by LSVT LOUD Certified Clinicians Have you noticed any stuttering in your speech? Do you experience food or liquid coming through your nose when you eat? Do you think your voice sounds nasal (i.e., hyper or hyponasal)? Have you previously had speech treatment? If yes, how long ago and what did you do? Was your previous speech treatment beneficial? If yes, what

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