Get the free Videostroboscopy Intake Form - St. Alexius Medical Center

St. Alexis Medical Center Rehabilitation Services Speech Department 900 East Broadway Ave., Bismarck, ND Phone: (701) 530-8200 Fax: (701) 530-8168 Videostroboscopy Patient History Form Name: Date:

How to fill out videostroboscopy intake form

How to fill out a videostroboscopy intake form:

1. Start by entering your personal information such as your full name, date of birth, address, and contact information. This is essential for identification and communication purposes.
2. Next, provide your medical history including any past or existing medical conditions, surgeries, medications, and allergies. It is important to provide accurate and detailed information to ensure proper assessment and care during the videostroboscopy procedure.
3. Indicate any symptoms or concerns related to your voice or throat that you are currently experiencing. This can include hoarseness, vocal fatigue, difficulty swallowing, or any other vocal abnormalities.
4. If applicable, mention any previous voice therapy or interventions you have undergone in relation to your voice concerns.
5. Include any relevant information about your lifestyle or occupation that may have an impact on your vocal health. This can include professional voice use, smoking habits, exposure to environmental factors, or frequent voice strain.
6. Lastly, read through the form carefully to ensure all information provided is accurate and complete. If there are any additional comments or questions you have, feel free to include them in the designated space provided.

Who needs a videostroboscopy intake form:

1. Individuals who are experiencing voice-related problems such as hoarseness, vocal cord nodules, vocal cord paralysis, or any other voice disorders may need to fill out a videostroboscopy intake form. This form helps gather relevant information about their medical history, symptoms, and concerns to assist in the diagnosis and treatment planning.
2. People who work in professions that heavily rely on their voice, such as singers, actors, teachers, or public speakers, may also need to complete a videostroboscopy intake form. This is to assess their vocal health and identify any potential issues that may affect their performance or vocal longevity.
3. Patients who have been referred by their primary care physician or an otolaryngologist (ear, nose, and throat specialist) for further evaluation or treatment of their voice-related concerns may be required to fill out a videostroboscopy intake form. This helps the specialists gather vital information and understand the nature of the problem before the actual videostroboscopy procedure.

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What is videostroboscopy intake form?

Videostroboscopy intake form is a document used to collect relevant information from patients prior to undergoing a videostroboscopy procedure.

Who is required to file videostroboscopy intake form?

Patients who are scheduled to undergo a videostroboscopy procedure are required to fill out the videostroboscopy intake form.

How to fill out videostroboscopy intake form?

Patients can fill out the videostroboscopy intake form by providing accurate and complete information about their medical history, symptoms, and contact details.

What is the purpose of videostroboscopy intake form?

The purpose of videostroboscopy intake form is to ensure that healthcare providers have necessary information about the patient's condition and medical history prior to the procedure.

What information must be reported on videostroboscopy intake form?

Information such as medical history, current symptoms, allergies, medications, and contact details must be reported on the videostroboscopy intake form.