Dysphagia Self-Assessment Screening Form
Full Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Have you experienced any of the following symptoms? (Select all that apply)
Frequent coughing or throat clearing during meals
Choking or gagging during meals
Pain or discomfort when swallowing
Frequent feeling of food sticking in the throat or upper chest
Increased effort or time to complete a meal
Weight loss related to eating difficulties
Frequent heartburn or acid reflux
Need to wash down food with a lot of liquid during meals
Feeling feverish after a meal
Shortness of breath during or after eating
Chronic congestion and/or frequent respiratory illnesses
Frequent feeling that food or liquid is going down the wrong pipe
Changing the types of food you eat or liquids you drink because it's easier
Coughing 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 toast
Hard raw fruits and vegetables such as carrots, celery, apples, pears etc
Fibrous meats such as steak, pork or ham
Foods that fall apart in the mouth like hamburger
Hard 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, pasta
Soft foods that don't require chewing such as yogurt, mashed potatoes, oatmeal, pudding
Blenderized/puree foods
Ready to drink liquid "nutritional" drinks like Ensure
Home made protein shakes
Do you have or have you ever experienced any of the following conditions? (Select all that apply)
Stroke
Parkinson's Disease
ALS
Multiple Sclerosis
Cerebral Palsy
Mysanthenia Gravis
Muscular Dystrohy
Head/brain trauma
Brain tumor
Brain Surgery
Heart Surgery
Anteror Neck Surgery for Cervical Spine
Other Neck Surgery
Acid Reflux Disease
Poliomyelitis
Radiation to the neck/throat
Cervical 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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