Sydney Swallow Questionnaire

This questionnaire is designed to help us establish the severity of your swallowing problem. It is quite straightforward and should easily be completed within 10 minutes. All the information given will remain strictly confidential .

For each question place the slider on the line below to indicate how severe your swallowing problem is. For example. Put the slider towards the lefthand end of the line if your problem is only minor, in the middle if it is moderate and at the righthand end if you have severe difficulty. If you have NO problem or difficulty asked about in the question you should place the slider at the FAR LEFTHAND end of the line.

1. How much difficulty do you have swallowing at present ? * must provide value
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
2. How much difficulty do you have swallwing THIN liquids ? * must provide value
(eg: tea, soft drink, beer,coffee)
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
3. How much difficulty do you have swallwing THICK liquids ? * must provide value
(eg: milkshakes, soup, custard)
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
4. How much difficulty do you have swallwing SOFT foods ? * must provide value
(eg: mornays, scrambled egg, mashed potato)
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
5. How much difficulty do you have swallwing HARD foods ? * must provide value
(eg: steak, raw fruit, raw vegetables)
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
6. How much difficulty do you have swallwing DRY foods ? * must provide value
(eg: bread, biscuits, nuts)
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
7. Do you have any difficulty swallwing your saliva ? * must provide value
NO DIFFICULTY
AT ALL
UNABLE TO SWALLOW
AT ALL
8. Do you have any difficulty starting a swallow ? * must provide value
NEVER
OCCURS
OCCURS EVERY TIME
I SWALLOW
9. Do you ever have a feeling of food getting stuck in your throat when you swallow ? * must provide value
NEVER
OCCURS
OCCURS EVERY TIME
I SWALLOW
10. Do you ever cough or choke when swallowing solid foods ? * must provide value
(eg: bread, meat or fruit)
NEVER
OCCURS
OCCURS EVERY TIME
I EAT
11. Do you ever cough or choke when swallowing liquids ? * must provide value
(eg: coffee, tea, water, beer)
NEVER
OCCURS
OCCURS EVERY TIME
I DRINK
12. How long does it take you to eat an average meal ? * must provide value
Please TICK ONE.
Less than 15 minutes
About 15-30 minutes
About 30-45 minutes
About 45-60 minutes
More than 60 minutes
Unable to swallow at all





13. When you swallow does food or liquid go up behind your nose or come out of your nose ? * must provide value
NEVER
OCCURS
OCCURS EVERY TIME
I SWALLOW
14. Do you ever need to swallow more than once for your food to go down ? * must provide value
NEVER
OCCURS
OCCURS EVERY TIME
I SWALLOW
15. Do you ever cough up or spit out food or liquids DURING a meal ? * must provide value
NEVER
OCCURS
OCCURS EVERY TIME
I EAT OR DRINK
16. How do you rate the severity of your swallowing problem today ? * must provide value
NO
PROBLEM
EXTREMELY SEVERE
PROBLEM
17. How much does your swallowing problem interfere with your enjoyment or quality of life ? * must provide value
NO
INTERFERENCE
EXTREME
INTERFERENCE