Student Questionnaire for Stuttering Example [Edit & Download]

Part 1: General Information

1. What is your name (or initials)?
2. How old are you?
3. What grade are you in?
4. How long have you been aware of your stuttering?
5. Who have you talked to about your stuttering (e.g., family, friends, teacher, therapist)?

Part 2: Stuttering Experience

6. How often do you notice yourself stuttering?
   • A. Rarely
   • B. Sometimes
   • C. Often
   • D. Almost Always
7. Are there specific words or sounds that you find harder to say?
   • A. Yes
   • B. No
   If yes, please provide examples: ____________________________
8. Do you feel that your stuttering changes depending on the situation?
   • A. Yes
   • B. No
   If yes, when do you notice it changes? (e.g., when speaking to a group, friends, strangers): ____________________________
9. Do you avoid certain words or speaking situations because of your stuttering?
   • A. Yes
   • B. No

Part 3: Emotional Impact

10. How do you feel when you stutter?
    • A. Confident
    • B. Frustrated
    • C. Embarrassed
    • D. Other (please explain): ____________________________
11. Do you feel that others treat you differently because of your stuttering?
    • A. Yes
    • B. No
    If yes, how? _______________________________________
12. What would you like people to understand about your stuttering?

Part 4: Support and Goals

13. Have you received support for your stuttering (e.g., speech therapy, support groups)?
    • A. Yes
    • B. No
    If yes, what kind of support? ____________________________
14. What has helped you the most so far in managing your stuttering?
15. What are your goals for your speech? (e.g., feeling more confident, speaking more fluently, not avoiding situations): ____________________________
16. How can teachers or classmates support you better in school?
17. Is there anything else you’d like to share about your experience with stuttering?