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Dr Ali Aminazad

MD, FRACP, FCCP, MClinResMeth Respiratory and Sleep Physician Adjunct Lecturer Monash University

Dr Timothy Cheung

B.Pharm (Hons), MBBS, FRACP Specialist Respiratory and Sleep Physician

Dr Chuan Foo

MBBS (Hons), FRACP Specialist Respiratory and Sleep Physician

Dr Shahab Makki

FRACP Specialist Respiratory and Sleep Physician

Dr Sadie Porsa

MD, FRACP Respiratory and Sleep physician
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STOP-BANG Sleep Apnea Questionnaire

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Vocal Cord Dysfunction Questionnaire (VCD-Q)
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Home

Services

Information

Doctors

Forms & Referrals

Contact Us

Health Professionals

Patients

FAQ

Publications

Dr Ali Aminazad

Dr Timothy Cheung

Dr Chuan Foo

Dr Shahab Makki

Dr Sadie Porsa

Appointment Request Form

Lung Function Request Form

Home-Based Sleep Study Request Form

Medical Review Referral Form

Patient Registration Form

Medical History

Epworth Sleepiness Scale

STOP-BANG Sleep Apnea Questionnaire

Asthma Control Questionnaire Form

Vocal Cord Dysfunction Questionnaire (VCD-Q)

Forms

Vocal Cord Dysfunction Questionnaire (VCD-Q)

Fill all required fields (★) to submit the form.

Patient details:

Full Name:(Required)

Prefix First Last

Preferred name:

Date of birth:(Required)

DD slash MM slash YYYY

Mobile Number(Required)

Home Phone:

Address:

Email address(Required)

Height:(Required)

Weight:(Required)

• This is a questionnaire developed to help monitor symptoms in patients with a diagnosis of Vocal cord Dysfunction, or PVFM. • These are statements many people have used to describe their breathing symptoms and the effects of these symptoms on their lives. • Please circle the response that indicates how much you agree with each statement

1. My Symptoms are confined to my throat/upper chest.(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

2. I feel like I can’t get breath past a certain point in my throat/upper chest because of restriction(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

3. My breathlessness is usually worse when breathing in(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

4. My attacks typically come on very suddenly(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

5. I feel that there is something in my throat that I can’t clear(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

6. My attacks are associated with changes in my voice(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

7. My breathing can be noisy during attacks(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

8. I’m aware of other specific triggers that cause attacks(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

9. My symptoms are associated with an ache or itch in my throat(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

10. I am frustrated that my symptoms have not been understood correctly(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

11. I am unable to tolerate any light pressure around the neck – e.g. tight clothes or bending the neck(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

12.The attacks impact on my social life(Required)

1 : Strongly Disagree

2 : Disagree

3 : Neither Agree or Disagree

4 : Agree

5 : Strongly Agree

Scoring:

Confirm:(Required)

I confirm that the above information is complete and correct.(Required)

Respiratory Sleep disorder Centre

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