Voice Disability Index First Name Last Name Date MM DD YYYY VOICE DISABILITY INDEX Because of my voice problem, my WORK is impaired (1 - 7) (1 = not at all; 2 - 3 = mildly; 4 - 5 = moderately; 6 = markedly; 7 = very severely) Because of my voice problem, my SOCIAL LIFE/LEISURE is impaired (1 - 7) (1 = not at all; 2 - 3 = mildly; 4 - 5 = moderately; 6 = markedly; 7 = very severely) Because of my voice problem, my FAMILY LIFE/HOME RESPONSIBILITY is impaired (1 - 7) (1 = not at all; 2 - 3 = mildly; 4 - 5 = moderately; 6 = markedly; 7 = very severely) Thank you!
