Select all of the symptoms you are currently experiencing.
Which symptoms are you experiencing? Please check all that apply.
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Inability to swallow
Coughing/throat clearing while eating & drinking
Choking/gagging while eating & drinking
Feeling like something is stuck in your throat or chest
Shortness of breath/fatigue when eating, drinking, & taking pills
Weak cough
Inability to cough
Long-term chest congestion
Recurring fever
Hoarseness/breathiness
Loud/noisy swallowing
Heartburn
Burning in the throat
Food coming back up in the throat
Chest pain when eating & drinking
"Wet" sounding voice
Pain when swallowing
Abnormally long time to eat
Loss of appetite/Weight loss/Malnutrition/Poor intake
Food/drinks falling out of your mouth
None of the above
Other
Other Contributing Factors
Tube feeding
Severe weakness
Require assistance in the home
Unable to live independently
Living in an institutional setting
Missing teeth/poor condition of teeth/excess plaque/bleeding gums/dental infection
Unable to feed yourself
Bed bound/Limited mobility
Recently hospitalized for pneumonia
Multiple medical conditions
None of the above
Health Conditions
Lung Disease
Neurological
GI Disease
Cancer
Psychiatric Disorder
Autoimmune & Rheumatological Disorder
None of the above
Other
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Health Conditions
Lung Disease
Covid-19
COPD
Asthma
Lung cancer
Pneumonia
Recurrent pneumonia
Aspiration pneumonia
Respiratory failure
Prolonged intubation
Tracheostomy tube
None of the above
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Neurological
Stroke/TIA
Parkinson's disease
ALS (Lou Gherig's disease)
Multiple sclerosis
Muscular dystrophy
Huntington's chorea
Traumatic brain injury
Brain surgery/tumor
Progressive supranuclear palsey
Alzheimer's
Dementia
Prader-Willi syndrome
None of the above
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GI Disease
Reflux (GERD/LPR) dysmotility
Hiatal hernia
Schiatzki ring
Stricture
Diverticulum
Stomach & intestinal disease
Eosinophilic esophagitis
None of the above
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Cancer
Head and neck
Esophageal
Lung
Stomach
Intestinal
Breast
None of the above
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Psychiatric Disorders
Mood disorder
Despression
Anxiety
Schizophrenia
Bi-polar disorder
Anorexia
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Autoimmune & Rheumatological Disease
HIV/AIDS
Wegener's granulomatosis
Polymtostics/Dermatomyostis
Inflammatory disorders
Guiilain Barre
Stiff person syndrome
Scleroderma
Sjogen's disease
Systemic lupus erythematosus
Rheumatoid arthritis
Behcet's disease
Anti-neutrophil cytoplasmic antibody
None of the above
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Other
Vocal fold/Vocal cord disorders
Alcohol/Drug use/abuse/overdose
Heart disease
UTI/recurrent UTI
None of the above
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