Stuttering Self-Assessment Questionnaire

Welcome to CCRA's Questionnaire for People Who Stutter.

Do you have problems with any of the following:

- Fluency of speech
- Maintaining normal fluency and time patterning of speech

Do these problems interfere with your academic or occupational achievement or with your ability to communicate?

If so, read on...

We'd like you to answer some questions in regard to the study we are conducting to help us determine your eligibility. Please check any of the statements that apply to you. In the comment space, you may list additional symptoms or information that you'd like us to have.

Your name:

Please enter your zip code:

What is your gender?

Female

Male

What is your age?

What age did your stuttering begin?

Are you currently on medication to treat suffering?

Yes

No

Have you had any speech therapy in the last 5 months?

Yes

No

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