Voice Evaluation Report

Patient Name: [Patient name]

DOB: [Date of birth]

MRN: [Medical record number]

Date of Service: [Date]

Referring Provider: [Referring clinician name and credentials]

Reason for Referral: [Reason for referral]

(When information is not available in the source, omit that content rather than inserting placeholders, except always document laryngeal visualization status. Do not infer medical diagnoses or endoscopic findings. Attribute all medical findings to the source document and date.)

Reason for Evaluation

[Patient-stated concern in own words, if available]. [Functional impact on work, social participation, or daily activities]. [Primary evaluation question or purpose]. (Write 2–4 concise sentences.)

Case History

[Symptom onset and course: acute/gradual, duration, progression]. [Symptom variability, identified triggers and relievers]. [Associated symptoms: throat clearing, cough, globus, fatigue, effort, or other]. [Relevant medical/surgical history including head/neck procedures, intubation, respiratory or neurologic conditions]. [Current medications relevant to voice]. [Substance use and hydration patterns: tobacco, alcohol, caffeine, water]. (Attribute medical history elements to their source if drawn from chart or outside note.)

• Voice Use Profile: [Occupation and primary vocal roles]; [Estimated daily voice use hours]; [Speaking environments and background noise]; [Use of amplification]; [Noise exposure].
• Professional Voice Details: [Singer/actor/teacher/other]; [Genre]; [Performance demands]; [Range/registration concerns]. (Only include if relevant.)
• Laryngeal Visualization Status: [Completed on (date) by (provider); key findings summarized as attributed to ENT note] / [Pending / Scheduled (date) / Recommended prior to initiating direct voice therapy]. (If not yet completed, note that therapy recommendations may be provisional pending visualization.)
• Patient-Identified Goals:
  • [Goal 1 linked to functional participation]
  • [Goal 2]
  • [Goal 3]

Patient-Reported Outcome Measures

(If no standardized instruments were administered, state this and provide the reason.)

Measure	Score	Interpretation
[Instrument name, e.g., VHI-10, V-RQOL, VFI]	[Score]	[Brief interpretation]
[Additional measure]	[Score]	[Brief interpretation]

Clinical Observations

[Communication effectiveness during session; visible effort or tension patterns in face, neck, or shoulders; breath holding or paradoxical patterns; throat clearing or cough behaviors; posture and body mechanics relevant to phonation; patient awareness and self-monitoring of voice behaviors]. (Use concise bullets or narrative; include only observed behaviors.)

Oral-Peripheral Examination

[Oral mechanism findings relevant to voice]. [Laryngeal palpation findings if performed: extrinsic laryngeal tension, tenderness, patient-reported sensations]. (Summarize normal findings succinctly. If not performed, state reason such as telehealth limitation.)

Respiratory-Phonatory Assessment

(Document breathing patterns and breath-voice coordination. Include number of trials and best or average values.)

Task	Metric	Trials	Result	Interpretation
Maximum phonation time (/a/)	MPT (sec)	[n]	[Value]	[Interpretation relative to age/sex norms if available]
/s/ and /z/ prolongation	s/z ratio	[n]	[s]= ; [z]= ; ratio=	[Interpretation with appropriate caution]

Breath Group Length (connected speech): [Qualitative or quantitative description].

Auditory-Perceptual Assessment

Protocol: [CAPE-V / clinic protocol] (Reference by name only; do not reproduce licensed forms.)

Speech Tasks Sampled: [Sustained vowels, sentences, connected speech / reading / conversation].

• Overall Severity: [Descriptor and/or rating]
• Roughness: [Descriptor/Rating]
• Breathiness: [Descriptor/Rating]
• Strain: [Descriptor/Rating]
• Pitch: [Descriptor/Rating; appropriateness and variability]
• Loudness: [Descriptor/Rating; adequacy and variability]
• Additional Features: [Tremor, instability, aphonia breaks, phonatory breaks, or other]. (Include only if present.)
• Consistency Across Tasks: [Consistent / Variable; specify]

[Brief interpretive statement linking perceptual profile to functional impact]. (Perceptual ratings describe voice quality and do not establish medical etiology.)

Instrumental Assessment

(Include this section only if acoustic or aerodynamic measures were obtained.)

Equipment and Conditions: [Hardware/software]; [Recording conditions and any validity limitations].

Task	Metric	Value	Interpretation
[Sustained vowel / Connected speech]	[CPP/CPPS, F0, SPL, or other]	[Value]	[Clinical interpretation]
[Aerodynamic task]	[Mean airflow, phonation threshold pressure, or other]	[Value]	[Clinical interpretation]

Laryngeal Imaging Findings

[Summary of visualization findings as stated in ENT/medical note: lesion characterization, glottic closure pattern, vocal fold mobility, vibratory features if reported, and any medical diagnosis provided]. (Attribute directly: "Per ENT [Provider], [Date]: …") (If visualization has not been completed, explicitly state status and note that therapy plan is provisional or that referral is recommended before initiating direct voice therapy.)

Stimulability and Therapeutic Probes

(Document techniques trialed, cueing provided, observed response, patient-perceived effort/comfort, and transfer potential. Note any safety concerns such as pain or fatigue.)

Technique	Cueing	Response	Transfer/Notes
[Technique name]	[Type and level of cues]	[Observed change; patient-reported effort/comfort]	[Transfer to connected speech; safety notes]
[Technique name]	[Cues]	[Response]	[Notes]

Contributing Factors

• Modifiable: [Vocal load, environmental noise, hydration, behavioral patterns, stress, technique/habits, sleep, medication effects].
• Non-modifiable: [Anatomical/medical conditions as reported, occupational constraints, chronic conditions].
• Facilitators: [Motivation, support, resources].
• Barriers: [Time, access, financial, medical factors].

Clinical Summary

[Synthesized interpretation connecting perceptual and objective findings to functional limitations. Key contributing factors and stimulability results informing treatment approach. Overall impression using scope-appropriate language such as "voice presentation consistent with" or "features suggestive of"]. (1–2 paragraphs. Use scope-appropriate language; state medical diagnoses only if documented by a qualified provider with attribution. Avoid repeating raw data from prior sections.)

Assessment

• SLP Problem Statement: [Voice disorder characteristics and functional impact]
• Medical Diagnosis: [Diagnosis] (Attributed to [provider, date]). (Include only if provided by qualified clinician.)
• Treatment Diagnosis / ICD-10 Code: [Code and description]

Plan of Care

Medical Necessity: [Explanation of why skilled SLP services are required and complexity factors supporting recommended intensity]. (2–3 sentences.)

• Frequency/Duration: [Visits per week] for [Total weeks or visits]; [Session length in minutes].
• Reassessment Interval: [Timeframe].

Long-Term Goals:

• [LTG 1: Functional participation outcome with measurable voice-use target and timeframe]
• [LTG 2] (Include if applicable.)

Short-Term Goals:

• [STG: Patient will produce (target) in (context) at (loudness/pitch) with (cue level), progressing from baseline (value) to (criterion) within (timeframe).]
• [STG: Additional skill-focused goal with baseline, criterion, cueing, and timeframe.]

Planned Interventions:

• Direct: [Techniques selected based on stimulability]; [Dosage parameters].
• Indirect: [Vocal hygiene education, hydration counseling, cough/throat-clear reduction, stress management strategies].
• Environmental Modifications: [Amplification recommendations, workplace/school modifications, scheduling/rest breaks].
• Care Coordination: [Communication with ENT, primary care, or other disciplines as indicated].

Home Program: [Exercise descriptions with dosage (reps, frequency, duration)]; [Technique cues]; [Self-monitoring plan such as effort ratings or voice logs]; [Safety precautions and stop rules for pain, hoarseness escalation, or fatigue].

Recommendations and Follow-up

1. [Referrals indicated, including ENT if not completed or additional specialties as appropriate].
2. [Urgent escalation criteria or red flags provided to patient/caregiver].
3. [Follow-up plan: scheduling, reassessment timing, coordination].

Clinician Signature: [Name, Credentials]    Date: [Date]