Client Questionnaire

Patient Intake Questionnaire

Before your first visit to MSAC, we encourage you to complete this online questionnaire, that aims to better understand your symptoms, concerns, general medical background and the reasons for your referral and visit. It will also ensure that your visit with us is more efficient and targeted towards what impacts you most.

Questionnaire - Step 1 of 3

Your Details

Name *

First

Last

Date of Birth *

Phone *

To which Gender Identity do you most Identify *

Female
Male
Transgender Female
Transgender Male
Gender Variant / Non-conforming
Not listed - please add below

Your Occupation *

Section 1

Do you have trouble swallowing? *

Yes
No (If No, Skip to Section 3)

Section 2

When did you first become concerned about your swallowing (estimate date)?

Did the problem begin

Suddenly
Gradually
Unsure

Is it getting

Worse
Better
About the Same

Your swallowing ability is:

Normal
Difficult
Very Difficult

Do you feel that food, liquids or pills get stuck?

Where do you feel food or liquid gets stuck (refer to figure below)?

a (upper neck)
b (lower neck)
c (chest)
d (under sternum / stomach)
other

If other please comment

Do you avoid certain FOODS because of difficulties swallowing?

Yes
No
Occasionally

Do you avoid certain LIQUIDS because of difficulty swallowing?

Yes
No
Occasionally

Other comments

Do you have pain upon swallowing?

Are there things you have stopped doing because of your swallowing problem?

If Yes, please describe.

Have you had any choking episodes?

Have you had any previous swallow evaluation(s)?

If Yes, Please list where and when previous tests were performed:

Do you have:

Own teeth
Full set of dentures
Partial set of dentures
No teeth

Section 3 - What do you normally eat?

Foods: IDDSI Levels 3-7 (choose one that best describes your diet)

7 - Regular foods
7 - East to chew
6 - Soft and bite-sized
5 - Minced and moist
4 - Pureed
3 - Liquidised
- No Solids

Drinks: IDDSI Levels 0-4 (choose one that best describes your diet)

0 - Thin drinks
1 - Slightly thick
2 - Mildly thick
3 - Moderately thick
4 - Extremely thick
- No Drinks

Nothing or limited oral intake by mouth:

Tube feeding and limited oral intake
Tube feeding an no oral intake

Has your swallowing problem caused you to lose weight?

Section 4 - Other history

Have you noticed any changes in your speech/ voice?

Do you smoke cigarettes / VAPE?

Currently smoke / VAPE
Yes, in the past
Never

Please specify home many cigarettes per day you smoke & for how many years you have been smoking for.

Do you drink alcohol?

Please specify the number of drinks consumed per day.

Do you suffer from Gastro-Oesophageal-Reflux-Disease / Laryngopharyngeal Reflux Disease?

Do you take medication for this?

If Yes, what medication?

Have you had pneumonia in the last 2 years?

Have you had surgery to your larynx/ neck?

If Yes, please describe

Section 5 - Reflux Severity Index (RSI)

These 9 statements many people have used to describe their voices and the effects of their voices on their lives

In the last 1 month, how did the following problems affect you?

Please indicate Severity from 0 to 5.

Reflux Severity Index (RSI) *

	0 - No problem	1 - Very mild problem	2 - Mild problem	3 - Moderate problem	4 - Severe problem	5 - Problem as bad as can be
Hoarseness or a problem with your voice	0 - No problemHoarseness or a problem with your voice 0 - No problem	1 - Very mild problemHoarseness or a problem with your voice 1 - Very mild problem	2 - Mild problemHoarseness or a problem with your voice 2 - Mild problem	3 - Moderate problemHoarseness or a problem with your voice 3 - Moderate problem	4 - Severe problemHoarseness or a problem with your voice 4 - Severe problem	5 - Problem as bad as can beHoarseness or a problem with your voice 5 - Problem as bad as can be
Clearing your throat	0 - No problemClearing your throat 0 - No problem	1 - Very mild problemClearing your throat 1 - Very mild problem	2 - Mild problemClearing your throat 2 - Mild problem	3 - Moderate problemClearing your throat 3 - Moderate problem	4 - Severe problemClearing your throat 4 - Severe problem	5 - Problem as bad as can beClearing your throat 5 - Problem as bad as can be
Excess throat mucous or post nasal drip	0 - No problemExcess throat mucous or post nasal drip 0 - No problem	1 - Very mild problemExcess throat mucous or post nasal drip 1 - Very mild problem	2 - Mild problemExcess throat mucous or post nasal drip 2 - Mild problem	3 - Moderate problemExcess throat mucous or post nasal drip 3 - Moderate problem	4 - Severe problemExcess throat mucous or post nasal drip 4 - Severe problem	5 - Problem as bad as can beExcess throat mucous or post nasal drip 5 - Problem as bad as can be
Difficulty swallowing liquids or pills	0 - No problemDifficulty swallowing liquids or pills 0 - No problem	1 - Very mild problemDifficulty swallowing liquids or pills 1 - Very mild problem	2 - Mild problemDifficulty swallowing liquids or pills 2 - Mild problem	3 - Moderate problemDifficulty swallowing liquids or pills 3 - Moderate problem	4 - Severe problemDifficulty swallowing liquids or pills 4 - Severe problem	5 - Problem as bad as can beDifficulty swallowing liquids or pills 5 - Problem as bad as can be
Coughing are your eat or lie down	0 - No problemCoughing are your eat or lie down 0 - No problem	1 - Very mild problemCoughing are your eat or lie down 1 - Very mild problem	2 - Mild problemCoughing are your eat or lie down 2 - Mild problem	3 - Moderate problemCoughing are your eat or lie down 3 - Moderate problem	4 - Severe problemCoughing are your eat or lie down 4 - Severe problem	5 - Problem as bad as can beCoughing are your eat or lie down 5 - Problem as bad as can be
Breathing difficulties or choking episodes	0 - No problemBreathing difficulties or choking episodes 0 - No problem	1 - Very mild problemBreathing difficulties or choking episodes 1 - Very mild problem	2 - Mild problemBreathing difficulties or choking episodes 2 - Mild problem	3 - Moderate problemBreathing difficulties or choking episodes 3 - Moderate problem	4 - Severe problemBreathing difficulties or choking episodes 4 - Severe problem	5 - Problem as bad as can beBreathing difficulties or choking episodes 5 - Problem as bad as can be
Troublesome or annoying cough	0 - No problemTroublesome or annoying cough 0 - No problem	1 - Very mild problemTroublesome or annoying cough 1 - Very mild problem	2 - Mild problemTroublesome or annoying cough 2 - Mild problem	3 - Moderate problemTroublesome or annoying cough 3 - Moderate problem	4 - Severe problemTroublesome or annoying cough 4 - Severe problem	5 - Problem as bad as can beTroublesome or annoying cough 5 - Problem as bad as can be
Sensations of something sticking in your throat, or a lump in your throat	0 - No problemSensations of something sticking in your throat, or a lump in your throat 0 - No problem	1 - Very mild problemSensations of something sticking in your throat, or a lump in your throat 1 - Very mild problem	2 - Mild problemSensations of something sticking in your throat, or a lump in your throat 2 - Mild problem	3 - Moderate problemSensations of something sticking in your throat, or a lump in your throat 3 - Moderate problem	4 - Severe problemSensations of something sticking in your throat, or a lump in your throat 4 - Severe problem	5 - Problem as bad as can beSensations of something sticking in your throat, or a lump in your throat 5 - Problem as bad as can be
Heartburn, chest pain, indigestions, or stomach acid coming up	0 - No problemHeartburn, chest pain, indigestions, or stomach acid coming up 0 - No problem	1 - Very mild problemHeartburn, chest pain, indigestions, or stomach acid coming up 1 - Very mild problem	2 - Mild problemHeartburn, chest pain, indigestions, or stomach acid coming up 2 - Mild problem	3 - Moderate problemHeartburn, chest pain, indigestions, or stomach acid coming up 3 - Moderate problem	4 - Severe problemHeartburn, chest pain, indigestions, or stomach acid coming up 4 - Severe problem	5 - Problem as bad as can beHeartburn, chest pain, indigestions, or stomach acid coming up 5 - Problem as bad as can be

Please answer every question

EAT-10

This questionnaire helps to measure swallowing difficulties

These are statements many people have used to describe difficulty swallowing / eating

To what extent do you experience the following problems?

Please indicate Severity from 0 to 5

EAT-10 *

	0 - No problem	1 - Very mild problem	2 - Mild problem	3 - Moderate problem	4 - Severe problem
My swallowing problem has caused me to lose weight	0 - No problemMy swallowing problem has caused me to lose weight 0 - No problem	1 - Very mild problemMy swallowing problem has caused me to lose weight 1 - Very mild problem	2 - Mild problemMy swallowing problem has caused me to lose weight 2 - Mild problem	3 - Moderate problemMy swallowing problem has caused me to lose weight 3 - Moderate problem	4 - Severe problemMy swallowing problem has caused me to lose weight 4 - Severe problem
My swallowing problem interferes with my ability to go out for meals	0 - No problemMy swallowing problem interferes with my ability to go out for meals 0 - No problem	1 - Very mild problemMy swallowing problem interferes with my ability to go out for meals 1 - Very mild problem	2 - Mild problemMy swallowing problem interferes with my ability to go out for meals 2 - Mild problem	3 - Moderate problemMy swallowing problem interferes with my ability to go out for meals 3 - Moderate problem	4 - Severe problemMy swallowing problem interferes with my ability to go out for meals 4 - Severe problem
Swallowing liquids takes extra effort	0 - No problemSwallowing liquids takes extra effort 0 - No problem	1 - Very mild problemSwallowing liquids takes extra effort 1 - Very mild problem	2 - Mild problemSwallowing liquids takes extra effort 2 - Mild problem	3 - Moderate problemSwallowing liquids takes extra effort 3 - Moderate problem	4 - Severe problemSwallowing liquids takes extra effort 4 - Severe problem
Swallowing solids takes extra effort	0 - No problemSwallowing solids takes extra effort 0 - No problem	1 - Very mild problemSwallowing solids takes extra effort 1 - Very mild problem	2 - Mild problemSwallowing solids takes extra effort 2 - Mild problem	3 - Moderate problemSwallowing solids takes extra effort 3 - Moderate problem	4 - Severe problemSwallowing solids takes extra effort 4 - Severe problem
Swallowing pills takes extra effort	0 - No problemSwallowing pills takes extra effort 0 - No problem	1 - Very mild problemSwallowing pills takes extra effort 1 - Very mild problem	2 - Mild problemSwallowing pills takes extra effort 2 - Mild problem	3 - Moderate problemSwallowing pills takes extra effort 3 - Moderate problem	4 - Severe problemSwallowing pills takes extra effort 4 - Severe problem
Swallowing is painful	0 - No problemSwallowing is painful 0 - No problem	1 - Very mild problemSwallowing is painful 1 - Very mild problem	2 - Mild problemSwallowing is painful 2 - Mild problem	3 - Moderate problemSwallowing is painful 3 - Moderate problem	4 - Severe problemSwallowing is painful 4 - Severe problem
The pleasure of eating is affected by my swallowing	0 - No problemThe pleasure of eating is affected by my swallowing 0 - No problem	1 - Very mild problemThe pleasure of eating is affected by my swallowing 1 - Very mild problem	2 - Mild problemThe pleasure of eating is affected by my swallowing 2 - Mild problem	3 - Moderate problemThe pleasure of eating is affected by my swallowing 3 - Moderate problem	4 - Severe problemThe pleasure of eating is affected by my swallowing 4 - Severe problem
When I swallow food sticks in my throat	0 - No problemWhen I swallow food sticks in my throat 0 - No problem	1 - Very mild problemWhen I swallow food sticks in my throat 1 - Very mild problem	2 - Mild problemWhen I swallow food sticks in my throat 2 - Mild problem	3 - Moderate problemWhen I swallow food sticks in my throat 3 - Moderate problem	4 - Severe problemWhen I swallow food sticks in my throat 4 - Severe problem
I cough when I eat	0 - No problemI cough when I eat 0 - No problem	1 - Very mild problemI cough when I eat 1 - Very mild problem	2 - Mild problemI cough when I eat 2 - Mild problem	3 - Moderate problemI cough when I eat 3 - Moderate problem	4 - Severe problemI cough when I eat 4 - Severe problem
Swallowing is stressful	0 - No problemSwallowing is stressful 0 - No problem	1 - Very mild problemSwallowing is stressful 1 - Very mild problem	2 - Mild problemSwallowing is stressful 2 - Mild problem	3 - Moderate problemSwallowing is stressful 3 - Moderate problem	4 - Severe problemSwallowing is stressful 4 - Severe problem

Please answer every question

The questionnaire is now complete.

Thank you & please contact us if you have any further questions.

Numbers

Patient Intake Questionnaire

Your Details

Section 1

Section 2

Section 3 - What do you normally eat?

Section 4 - Other history

Section 5 - Reflux Severity Index (RSI)

These 9 statements many people have used to describe their voices and the effects of their voices on their lives

In the last 1 month, how did the following problems affect you?

The questionnaire is now complete.

Thank you & please contact us if you have any further questions.

Book an Appointment
Contact MSAC

Have some questions?
View FAQs Database

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Contact

Talk to Us

Email

Contact Form

Resources: Client Questionnaire

Patient Intake Questionnaire

Your Details

Section 1

Section 2

Section 3 - What do you normally eat?

Section 4 - Other history

Section 5 - Reflux Severity Index (RSI)

These 9 statements many people have used to describe their voices and the effects of their voices on their lives

In the last 1 month, how did the following problems affect you?

The questionnaire is now complete.

Thank you & please contact us if you have any further questions.

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