Eating Assessment Tool (EAT-10) Welcome to your Eating Assessment Tool (EAT-10) 1 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True My swallowing problem has caused me to lose weight. 0 1 2 3 4 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True My swallowing problems interferes with my ability to go out for meals. 0 1 2 3 4 None 3 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True Swallowing liquids takes extra effort. 0 1 2 3 4 None 4 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True Swallowing solids takes extra effort. 0 1 2 3 4 None 5 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True Swallowing pills takes extra effort. 0 1 2 3 4 None 6 6 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True Swallowing is painful. 0 1 2 3 4 None 7 7 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True The pleasure of eating is affected by my swallowing. 0 1 2 3 4 None 8 8 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True When I swallow food sticks in my throat. 0 1 2 3 4 None 9 9 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True I cough when I eat. 0 1 2 3 4 None 10 10 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 - 4 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True Swallowing is stressful. 0 1 2 3 4 None Name DOB Email Phone number Please contact me by email Please contact me by phone Time's up
