• DOV Questionnaire

    DOV Questionnaire

  • Image field 1
  • Today's Date (MM/DD/YYYY)*
     / /
  • *
  • Date of Birth (MM/DD/YYYY)*
     / /

  • This questionnaire is to assess for Dysphagia, Odynophagia and Voice (DOV). Dysphagia is difficulty swallowing meaning that it may take longer to finish meals or consume foods with certain textures. Odynophagia is pain with swallowing meaning that eating might cause pain requiring meals to be smaller. The voice component evaluates difficulty speaking loudly and clearly.

  • 1. Swallowing (pick the single best answer)*
  • 2. Voice (pick the single best answer)*
  • 3. Pain with Swallowing (pick the single best answer)*
  • Image field 13
  • Image field 14
  • Image field 15
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  • Should be Empty: