Subglottic Stenosis 6 Question Survey

Call To Discuss Your Vocal Health

Certified Practising Speech Pathologist, Cleveland

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Subglottic Stenosis 6 Question Survey (SSS-6)

The results of these questions will be sent to your Speech Pathologist who will discuss them with you at your next appointment.

Name *

First

Last

Date *

1. Please indicate which of the five responses below best describes your level of breathlessness over the past week. (Select one response only) *

I get short of breath only on strenuous exercise.
I get short of breath when hurrying on the level of climbing up a slight hill.
I walk slower than people of the same age on the level because of breathlessness, or have to stop for breath when walking at my own pace on the level.
I stop for breath after walking 100 yards or after a few minutes on the level.
I am too breathless to leave the house.

2. Consider the statement, I have difficulty catching my breath. Select one response that best matches your breathing these days. *

None
Mild
Moderate
Severe

3. On average during the past week, how much of the time did you cough? (Select one response only) *

None
Hardly ever
A few times
Several times
A great many times
Almost all the time

4. Consider the statement, My voice difficulties restrict my personal and social life. Select one response which best reflects your voice symptoms/difficulties. *

None
Almost never
Sometimes
Almost always
Always

5. On average, during the past week, how limited were your moderate physical activities (such as walking, housework, carrying things) because of your breathing problems? (Select one response only) *

Not limited at all
Very slightly limited
Slightly limited
Very limited
Extremely limited
Totally limited

6. In general, would you say your health is...(Select one response only) *

Excellent
Very good
Good
Fair
Poor

Jenny Matthews, Certified Practising Speech Pathologist at Bayside Voice Centre, has a special interest in voice and provides voice education and voice therapy services for clients to help them protect and optimise the quality of their voice.

Contact Us

Cleveland, Brisbane

(07) 3193 5436

Bayside Voice Centre

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Call To Discuss Your Vocal Health

Certified Practising Speech Pathologist, Cleveland

Subglottic Stenosis 6 Question Survey (SSS-6)

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