Cough Severity Index (CSI) Patient Reported Outcome Measure

Cough Severity Index (CSI) Patient Reported Outcome Measure

Source: Shembel, A. C., Rosen C.A, Zullo T.G. (2013).
Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Treatment Cycle:

New Patient Assessment no treatmentsRe-evaluation of established patient (3+ months since patient was last seen by this provider)received 1-3 treatmentsreceived 4-6 treatmentsreceived 7-9 treatmentsreceived 10-12 treatmentsI do not know how many treatments I received to date.
Treatment Cycle:
This questionnaire is designed to determine the severity and impact of your cough in your life.

These are statements many people have used to describe their cough and the effects cough has had on their life.

In the past week, how did the following problems affect you?

Please mark the response that indicates how OFTEN you experience the symptoms.

If you do not have a problem with coughing mark all responses zero (0) to these statements and submit.
Cough is worse when I lie down:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing causes me to restrict my personal, social or occupational activities:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing causes me avoid going places:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing causes me to feel embarrassed or draws negative or unwanted attention from others:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing causes others around me to ask "What's wrong" or assume I am sick because I cough so frequently:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing causes me to run out of air or to feel short of breath:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing negatively affects my voice and causes it to change or sound hoarse:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing limits my ability to be physical active:

NeverAlmost NeverSometimesAlmost alwaysAlways
Coughing causes me to feel upsets or frustrated:

NeverAlmost NeverSometimesAlmost alwaysAlways
People have asked me if I am sick because of how often I cough or how horrible the cough sounds:

NeverAlmost NeverSometimesAlmost alwaysAlways
Total Score
Impressions:

CSI score is 0-3. This is within normal limits and indicates that cough is not negatively impacting quality of life.CSI score is 4 or higher. This indicates that cough is having some degree of negative impact on quality of life.
Source: Shembel, A. C., Rosen C.A, Zullo T.G. (2013). "Development and validation of the cough severity index: a severity index for chronic cough related to the upper airway." Laryngoscope 123(8): 1931-1936.
Should be Empty: