Voice & Swallowing Questionaire
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
Patient’s First Name
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Last Name
*
MI
Birth Date
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Provider
*
Please Select
Valerie Asher, MD
David Bianchi, MD
Brian Driscoll, MD
Liesl Nottingham, MD
Hosai Todd-Hesham, MD
Mark Miller, MD
Anju Patel, MD
Unknown/Unlisted
Address
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City
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State
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Zip
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All Patients – RSI
ALL PATIENTS, please rate each question from 0-5 using the description: 0 = no problem, 5 = severe problem
1. Hoarseness or a problem with your voice
0
1
2
3
4
5
2. Clearing your throat
0
1
2
3
4
5
3. Excess throat mucous or postnasal drip
0
1
2
3
4
5
4. Difficulty swallowing food, liquid, or pills
0
1
2
3
4
5
5. Coughing after you ate or after lying down
0
1
2
3
4
5
6. Breathing difficulties or choking episodes
0
1
2
3
4
5
7. Troublesome or annoying cough
0
1
2
3
4
5
8. Sensation of something sticking in throat or a lump in your throat
0
1
2
3
4
5
9. Heartburn, chest pain, indigestion or stomach acid coming up
0
1
2
3
4
5
Swallowing Problems – EAT-10
IF YOU HAVE SWALLOWING PROBLEMS, FILL THIS OUT. Please rate each question from 0-4 using the description: 0 = no problem, 4 = severe problem
1. My swallowing problem has caused me to lose weight
0
1
2
3
4
2. My swallowing problem interferes with my ability to go out for meals
0
1
2
3
4
3. Swallowing liquids takes extra effort.
0
1
2
3
4
4. Swallowing solids takes extra effort
0
1
2
3
4
5. Swallowing pills takes extra effort
0
1
2
3
4
6. Swallowing is painful
0
1
2
3
4
7. The pleasure of eating is affected by my swallowing
0
1
2
3
4
8. When I swallow food sticks in my throat
0
1
2
3
4
9. I cough when I eat
0
1
2
3
4
10. Swallowing is stressful
0
1
2
3
4
Voice Problems – VHI-10
IF YOU HAVE VOICE PROBLEMS, FILL THIS OUT. Please rate each question from 0-4 using the description: 0 = no problem, 4 = severe problem
1. My voice makes it difficult for people to hear me
0
1
2
3
4
2. People have difficulty understanding me in a noisy room
0
1
2
3
4
3. My voice problems alter my personal and social life
0
1
2
3
4
4. I feel left out of conversations because of my voice
0
1
2
3
4
5. My voice problem affects my work performance
0
1
2
3
4
6. I need to strain to produce my voice
0
1
2
3
4
7. The quality of my voice is unpredictable
0
1
2
3
4
8. My voice bothers me
0
1
2
3
4
9. People seem irritated with my voice
0
1
2
3
4
10. People ask, “What’s wrong with your voice?”
0
1
2
3
4
Signature of Patient or Legal Guardian
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Date