Pill-5

1

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

0 = Never
1 = Very much True
2 = Quite a bit True
3 = Somewhat True
4 = A Little True
5 = Not at all True

Pills stick in my throat

None

2

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

0 = Never
1 = Very much True
2 = Quite a bit True
3 = Somewhat True
4 = A Little True
5 = Not at all True

Pills stick in my chest

None

3

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

0 = Never
1 = Very much True
2 = Quite a bit True
3 = Somewhat True
4 = A Little True
5 = Not at all True

I have a fear of swallowing pills

None

4

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

0 = Never
1 = Very much True
2 = Quite a bit True
3 = Somewhat True
4 = A Little True
5 = Not at all True

My problem swallowing pills interferes will my ability to take my medicine.

None

5

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

0 = Never
1 = Very much True
2 = Quite a bit True
3 = Somewhat True
4 = A Little True
5 = Not at all True

I can’t take my pills without crushing, coating, or using other forms of assistance.

None

Name

DOB

Phone number

Please contact me by email

Please contact me by phone

Pill-5

How to complete this Questionnaire:

1

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

2

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

3

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

4

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

5

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

Book an Appointment
Contact MSAC

Have some questions?
View FAQs Database

Open Map Location ( Minimise )

Contact

Talk to Us

Email

Contact Form

How to complete this Questionnaire:

1

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

2

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

3

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

4

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

5

Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 0 - 5 Rating Scale

Book an Appointment Contact MSAC

Have some questions? View FAQs Database

Open Map Location ( Minimise )

Contact

Talk to Us

Email

Contact Form

Book an Appointment
Contact MSAC

Have some questions?
View FAQs Database