Dysphagia Self-Assessment Screening Form

Dysphagia Self-Assessment Screening Form
Full Name*

First NameLast Name
Email Address*
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Phone Number
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Have you experienced any of the following symptoms? (Select all that apply)

Frequent coughing or throat clearing during mealsChoking or gagging during mealsPain or discomfort when swallowingFrequent feeling of food sticking in the throat or upper chestIncreased effort or time to complete a mealWeight loss related to eating difficultiesFrequent heartburn or acid refluxNeed to wash down food with a lot of liquid during mealsFeeling feverish after a mealShortness of breath during or after eatingChronic congestion and/or frequent respiratory illnessesFrequent feeling that food or liquid is going down the wrong pipeChanging the types of food you eat or liquids you drink because it's easierCoughing or choking on your own saliva
Do you avoid any of the following foods because they are difficult to swallow? (Select all that apply)

Bread and/or toastHard raw fruits and vegetables such as carrots, celery, apples, pears etcFibrous meats such as steak, pork or hamFoods that fall apart in the mouth like hamburgerHard and crunchy snacks like crackers, chips, pretzels etc
Do you often choose any of the following foods because they are easier to swallow? (Select all that apply)

Soft easily chewable foods such as cooked soft vegetables, canned fruits, bananas, pastaSoft foods that don't require chewing such as yogurt, mashed potatoes, oatmeal, puddingBlenderized/puree foodsReady to drink liquid "nutritional" drinks like EnsureHome made protein shakes
Do you have or have you ever experienced any of the following conditions? (Select all that apply)

StrokeParkinson's DiseaseALSMultiple SclerosisCerebral PalsyMysanthenia GravisMuscular DystrohyHead/brain traumaBrain tumorBrain SurgeryHeart SurgeryAnteror Neck Surgery for Cervical SpineOther Neck SurgeryAcid Reflux DiseasePoliomyelitisRadiation to the neck/throatCervical Osteophytes
If you checked any of the above items you may have dysphagia. The more items you checked the greater the chance you do. The good news is, there is hope, there is help. You've come to the right place! If you want more information just type in: "more info" in the box below. If you are not interested in any additional information type "no thanks" in the box below.
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