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.

NB: Before completing this form, please ensure that you have made an appointment with Jenny Matthews, through Redlands Specialist Centre, (07) 3193 5436. These forms are specifically designed for patients to complete prior to their initial assessment and after you have made an appointment, you will be advised which forms are necessary for you to complete, depending on the reason for your appointment. Because these forms do not collect your contact information, if you complete these forms before making an appointment we will have no way of contacting you to discuss the results.

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

Email *

Please enter your email address.

Jenny Matthews, a 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

Unit 19/16 Weippin St Cleveland, Brisbane

(07) 3193 5436

Bayside Voice Centre

Bayside Voice Centre would like to acknowledge the traditional custodians of Quandamooka & Yuggera Country where our clinics are located.

As Speech Pathologists, we recognise and value the importance of voice, story-telling and oral language to connect with Country, Culture and Community.

We pay our respect to Aboriginal and Torres Strait Islander Elders past, present and emerging who share history and hopes through the power of voice.

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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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