Reflux Severity Index (RSI) 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Hoarseness or a problem with your voice 0 1 2 3 4 5 None 2 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Clearing your throat 0 1 2 3 4 5 None 3 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Excess throat or mucous post-nasal drip 0 1 2 3 4 5 None 4 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Difficulty swallowing food, liquids or pills 0 1 2 3 4 5 None 5 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Coughing after you ate or after lying down 0 1 2 3 4 5 None 6 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Breathing difficulties or choking episodes 0 1 2 3 4 5 None 7 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Sensations of something sticking in your throat 0 1 2 3 4 5 None 8 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 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Heartburn, chest pain, indigestion, or stomach acid coming up 0 1 2 3 4 5 None Name DOB Email Phone number Please contact me by email Please contact me by phone Time's up
