Jacqui Allen Questionnaires Home > Procedures > Patient Resources > Jacqui Allen Questionnaires Jacqui Allen Questionnaires Please select the most appropriate response for each question.Within the last MONTH, how did the following problems affect you? 0 = no problem and 5 = severe/frequent problem REFLUX SYMPTOM INDEX Within the last Month, how did the following problems affect you? 0 = No problem 5 = Severe problem Hoarseness or a problem with your voice 0 1 2 3 4 5 Clearing your throat 0 1 2 3 4 5 Excess throat mucous or postnasal drip 0 1 2 3 4 5 Difficulty swallowing food, liquids, or pill 0 1 2 3 4 5 Coughing after you ate or after lying down 0 1 2 3 4 5 Breathing difficulties or choking episodes 0 1 2 3 4 5 Troublesome or annoying cough 0 1 2 3 4 5 Sensations of something sticking in your throat or a lump in your throat 0 1 2 3 4 5 Heartburn, chest pain, indigestion, or stomach acid coming up 0 1 2 3 4 5 EATING ASSESSMENT TOOL (EAT-10) To what extent are the following scenarios problematic for you? 0 = No problem 4 = Severe problem 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 VOICE HANDICAP INDEX - QUESTIONNAIRE 1. My voice makes it difficult for people to hear me Never Almost never Sometimes Almost always Always 2. People have difficulty understanding me in a noisy room Never Almost never Sometimes Almost always Always 3. My voice difficulties restrict personal and social life Never Almost never Sometimes Almost always Always 4. I feel left out of conversations because of my voice Never Almost never Sometimes Almost always Always 5. My voice problem causes me to lose income Never Almost never Sometimes Almost always Always 6. I feel as though I have to strain to produce voice Never Almost never Sometimes Almost always Always 7. The clarity of my voice is unpredictable Never Almost never Sometimes Almost always Always 8. My voice problem upsets me Never Almost never Sometimes Almost always Always 9. My voice makes me feel handicapped? Never Almost never Sometimes Almost always Always 10. People ask “what’s wrong with your voice?” Never Almost never Sometimes Almost always Always Submit Enquire now For more information on any of our procedures. Contact Us