Symptom

Score

My swallowing problem has caused me to lose weight.

0 1 2 3 4

My swallowing problem interferes with my ability to go out for meals.

0 1 2 3 4

Swallowing liquids takes extra effort.

0 1 2 3 4

Swallowing solids takes extra effort.

0 1 2 3 4

Swallowing pills takes extra effort.

0 1 2 3 4

Swallowing is painful.

0 1 2 3 4

The pleasure of eating is affected by my swallowing.

0 1 2 3 4

When I swallow food sticks in my throat.

0 1 2 3 4

I cough when I eat.

0 1 2 3 4

Swallowing is stressful.

0 1 2 3 4

Total score

/40