Reflux Symptom Index

Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Date Completed

MonthDayYear
Date
Reflux Symptom Index
How do the following affect you?
Hoarseness or a problem with your voice

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Clearing your throat

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Excess throat mucous or postnasal drip

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Difficulty swallowing food, liquids or pills

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Coughing after you eat or after lying down

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Breathing difficulties or choking episodes

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Troublesome or annoying cough

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Sensations of something sticking in your throat or a lump in your throat

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Heartburn, chest pain, indigestion, or acid coming up

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Total
*Note: A total score of 10 or less is normal. A total score of 13 or more suggests larygopharyngeal reflux.
SYMPTOMS OF LRP
Intermittent dysponia (difficulty producing speech)

YesNoMaybe
Sialorrhea (hypersalivation)

YesNoMaybe
Cervical dysphagia (difficulty swallowing)

YesNoMaybe
Dysgeusia (distorted sense of smell)

YesNoMaybe
Halitosis (bad breath)

YesNoMaybe
Throat pain

YesNoMaybe
Nasal Obstruction and Symptoms
Nasal congestion or stuffiness

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Nasal blockage or obstruction

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Trouble breathing through the nose

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Unable to get enough air through the nose during exercise

1

2

3

4

5

1 is No Problem, 5 is Severe Problem
Please indicate the difficulty to breathe through the nose

1

2

3

4

5

6

7

8

9

10

1 is No Difficulty, 10 is Severe
Should be Empty:

Reflux Symptom Index

How do the following affect you?

SYMPTOMS OF LRP

Nasal Obstruction and Symptoms