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New Patient Voice & Swallowing Questionaire

Maryland ENT logo

2415 Musgrove Road, Suite 203
Silver Spring, Maryland 20904
(301) 989-2300
Please use the exact same name that you used to schedule the appointment
All Patients – RSI
Please rate each question from 0-5 using the description: 0 = no problem, 5 = severe problem
1. Hoarseness or a problem with your voice  
2. Clearing your throat  
3. Excess throat mucous or postnasal drip  
4. Difficulty swallowing food, liquid, or pills  
5. Coughing after you ate or after lying down  
6. Breathing difficulties or choking episodes  
7. Troublesome or annoying cough  
8. Sensation of something sticking in throat or a lump in your throat  
9. Heartburn, chest pain, indigestion or stomach acid coming up  
Voice Problems – VHI-10
Are you having trouble with your voice?  
Breathing or Coughing Problems
Are you having trouble with your breathing (e.g. short of breath, noisy breathing, cough)?  
Swallowing Problems – EAT-10
Are you having trouble with your swallowing?  
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