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    Sydney Swallow Questionnaire: Name: - DOB/Sex: - Date

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    LADY MARIAN CASTAÑEDA MARANTA
    This document contains a 17-question swallowing questionnaire used to assess the severity of a patient's swallowing problems. It asks the patient to rate on a scale the difficulty they experience swallowing various foods and liquids. It also inquires about other swallowing issues like the time it takes to eat a meal or if food gets stuck. The questionnaire was developed and validated by researchers to help clinicians evaluate a patient's swallowing difficulties.

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    Sydney Swallow Questionnaire: Name: - DOB/Sex: - Date

    Uploaded by

    LADY MARIAN CASTAÑEDA MARANTA
    258 views4 pages
    This document contains a 17-question swallowing questionnaire used to assess the severity of a patient's swallowing problems. It asks the patient to rate on a scale the difficulty they experience swallowing various foods and liquids. It also inquires about other swallowing issues like the time it takes to eat a meal or if food gets stuck. The questionnaire was developed and validated by researchers to help clinicians evaluate a patient's swallowing difficulties.

    Original Title

    SSQ-21.09.2015 cuestionario Sydney

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    This document contains a 17-question swallowing questionnaire used to assess the severity of a patient's swallowing problems. It asks the patient to rate on a scale the difficulty they experience swallowing various foods and liquids. It also inquires about other swallowing issues like the time it takes to eat a meal or if food gets stuck. The questionnaire was developed and validated by researchers to help clinicians evaluate a patient's swallowing difficulties.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    258 views4 pages

    Sydney Swallow Questionnaire: Name: - DOB/Sex: - Date

    Uploaded by

    LADY MARIAN CASTAÑEDA MARANTA
    This document contains a 17-question swallowing questionnaire used to assess the severity of a patient's swallowing problems. It asks the patient to rate on a scale the difficulty they experience swallowing various foods and liquids. It also inquires about other swallowing issues like the time it takes to eat a meal or if food gets stuck. The questionnaire was developed and validated by researchers to help clinicians evaluate a patient's swallowing difficulties.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    THE ST GEORGE THE UNIVERSITY OF

    HOSPITAL Sydney NEW SOUTH WALES

    Swallow
    Questionnaire
    DEPARTMENT OF
    GASTROENTEROLOGY

    Name: _____________________
    DOB/Sex: __________________
    Date: ______________________

    This questionnaire is designed to help us establish the severity of your swallowing


    problem. It is quite straightforward and should easily be completed within 10 minutes. All
    the information given will remain strictly confidential.
    For each question put an “X” on the line below to indicate how severe your swallowing
    problem is. For example. Put the “X” towards the lefthand end of the line if your
    problem is only minor, in the middle if it is moderate and at the righthand end if you
    have severe difficulty. If you have NO problem or difficulty asked about in the question
    you should place “X” at the FAR LEFTHAND end of the line.

    1. How much difficulty do you have swallowing at present?

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL

    2. How much difficulty do you have swallowing THIN liquids?


    (eg: tea, soft drink, beer, coffee)

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL
    3. How much difficulty do you have swallowing THICK liquids?
    (eg: milkshakes, soups, custard)

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL

    4. How much difficulty do you have swallowing SOFT foods?


    (eg: mornays, scrambled egg, mashed potato)

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL

    5. How much difficulty do you have swallowing HARD foods?


    (eg: steak, raw fruit, raw vegetables)

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL

    6. How much difficulty do you have swallowing DRY foods?


    (eg: bread, biscuits, nuts)

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL

    7. Do you have any difficulty swallowing your saliva?

    NO DIFFICULTY UNABLE TO SWALLOW


    AT ALL AT ALL

    8. Do you have any difficulty starting a swallow?

    NEVER OCCURS EVERY TIME


    OCCURS I SWALLOW
    9. Do you ever have a feeling of food getting stuck in your throat when you
    swallow?

    NEVER OCCURS EVERY TIME


    OCCURS I SWALLOW

    10. Do you ever cough or choke when swallowing solid foods?


    (eg: bread, meat or fruit)

    NEVER OCCURS EVERY TIME


    OCCURS I EAT

    11. Do you ever cough or choke when swallowing liquids?


    (eg: coffee, tea, water, beer)

    NEVER OCCURS EVERY TIME


    OCCURS I DRINK

    12. How long does it take you to eat an average meal?


    Please TICK ONE.
    Less than 15 minutes _____
    About 15-30 minutes _____
    About 30-45 minutes _____
    About 45-60 minutes _____
    More than 60 minutes _____
    Unable to swallow at all _____

    13. When you swallow does food or liquid go up behind your nose or come out of
    your nose?

    NEVER OCCURS EVERY TIME


    OCCURS I SWALLOW
    14. Do you ever need to swallow more than once for your food to go down?

    NEVER OCCURS EVERY TIME


    OCCURS I SWALLOW

    15. Do you ever cough up or spit out food or liquids DURING a meal?

    NEVER OCCURS EVERY TIME


    OCCURS I EAT OR DRINK

    16. How do you rate the severity of your swallowing problem today?

    NO EXTREMELY SEVERE
    PROBLEM PROBLEM

    17. How much does your swallowing problem interfere with your enjoyment or
    quality of life?

    NO EXTREME
    INTERFERENCE INTERFERENCE

    THANK YOU FOR YOUR ASSISTANCE

    Investigator Note:
    1. Details of the development, validation and recommended analysis of the Sydney Swallow
    Questionnaire can be found in: Wallace KL, Middleton S and Cook IJ, Gastroeneterology
    2000; 118: 678-687
    2. Questionnaire and related documentation available at website:
    http://www.stgeorgeswallowcentre.org/ssq
     Gastroenterology Department, The St George Hospital and University of NSW, Sydney,
    AUSTRALIA. Can be reproduced in whole for clinical and research purposes only. Not to be
    reproduced for commercial purposes or resale.

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