Pill-5 Welcome to your Pill-5 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 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Pills stick in my throat 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 Pills stick in my chest 0 1 2 3 4 5 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 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True I have a fear of swallowing pills 0 1 2 3 4 5 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 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True My problem swallowing pills interferes will my ability to take my medicine. 0 1 2 3 4 5 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 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True I can’t take my pills without crushing, coating, or using other forms of assistance. 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
