| 1.What is your main complaint, the reason for your appointment? 2.How long after your symptoms began did you seek professional help? 3.Who was the first person who contacted for help? ( ) Dentist ( ) Physiotherapist ( ) Speech Therapist ( ) Doctor – general clinic ( ) Doctor – Otolaryngologist ( ) Doctor – Neurologist ( ) Doctor – Other specialty: _________ ( ) Other: ______________________________ |
| 4.Have you taken any medication based on your own decision (without a prescription) before seeking this help? ( ) YES, which medicine? ( ) NO |
| 5.When you took the medication you self-prescribed, did you ask anybody for help and if so, who? ( ) Pharmacist ( ) Clerk ( ) Friend/ Neighbor ( ) Relative ( ) Other __________________________________ |
| 6.Are you currently taking any medication? ( ) YES For what? Was it prescribed by a professional? ( ) YES ( ) NO |