Reflux Severity Index (RSI)

This questionnaire helps to measure swallowing difficulties. Simply answer 10 short questions to what extent do you experience the following problems.

1st

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

Hoarseness or a problem with your voice

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

Clearing your throat

None

3

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

Excess throat or mucous post-nasal drip

None

4

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 2 - 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

Difficulty swallowing food, liquids or pills

None

5

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

Coughing after you ate or after lying down

None

6

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

Breathing difficulties or choking episodes

None

7

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

Sensations of something sticking in your throat

None

8

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

Heartburn, chest pain, indigestion, or stomach acid coming up

None

Name

DOB

Phone number

Please contact me by email

Please contact me by phone

Time's up

"Belafsky, P. C., Postma, G. N., & Koufman, J. A. (2002). Validity and reliability of the reflux symptom index (RSI). J Voice, 16(2), 274-277"

Reflux Severity Index (RSI)

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 aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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 aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 2 - 5 Rating Scale

5

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

6

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

7

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

8

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

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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 aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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 aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement.

Degree of Problem 2 - 5 Rating Scale

5

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

6

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

7

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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

8

Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. 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