Pill-5

How to complete this questionnaire:

This questionnaire is designed to find out how your swallowing problem has been affecting your day-to-day quality of life.
Please take the time to carefully read and answer each question.
Some questions may look like others, but each one is different.
Important Note: We understand that you may have a number of physical problems. Sometimes it is hard to separate these from swallowing difficulties. But, we hope that you an do your best ot concentrate only on your swallowing problem. Thank you for your efforts in completing this questionnaire.

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

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Contact MSAC

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View FAQs Database

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Talk to Us

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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