| Functional score | F1. My voice makes it difficult for people to hear me |
| F2. People have difficulty understanding me in a noisy room |
| F3. My family has difficulty hearing me when I call them throughout the house |
| F4. I use the phone less often than I would like to |
| F5. I tend to avoid groups of people because of my voice |
| F6. I speak with friends, neighbors, or relatives less often because of my voice |
| F7. People ask me to repeat myself when speaking face to face |
| F8. My voice difficulties restrict personal and social life |
| F9. I feel left out of conversations because of my voice |
| F10. My voice problem causes me to lose income |
| Physical score | P1. I run out of air when I talk |
| P2. The sound of my voice varies throughout the day |
| P3. People ask, "What's wrong with your voice?" |
| P4. My voice sounds creaky and dry |
| P5. I feel as though I have to stain to produce voice |
| P6. The clarity of my voice is unpredictable |
| P7. I try to change my voice to sound different |
| P8. I use a great deal of effort to speak |
| P9. My voice is worse in the evening |
| P10. My voice "gives out" on me in the middle of speaking |
| Emotional score | E1. I am tense when talking to others because of my voice |
| E2 People seem irritated with my voice |
| E3. I find other people don't understand my voice problem |
| E4. My voice problem upsets me |
| E5. I am less outgoing because of my voice problem |
| E6. My voice makes me feel handicapped |
| E7. I feel annoyed when people ask me to repeat |
| E8. I feel embarrassed when people ask me to repeat |
| E9. My voice makes me feel incompetent |
| E10. I am ashamed of my voice problem |