REFLUX COUGH QUESTIONNAIRE
Name:_________________________________________________
D.O.B:____________________________ UN: _________________
DATE OF TEST:_________________________________________
Please circle the most appropriate response for each question
Within the last MONTH, how did the following problems affect you? 0 = no problem and 5 = severe/frequent problem |
||||||
Hoarseness or a problem with your voice |
0 |
1 |
2 |
3 |
4 |
5 |
Clearing your throat |
0 |
1 |
2 |
3 |
4 |
5 |
The feeling of something dripping down the back of your nose or throat |
0 |
1 |
2 |
3 |
4 |
5 |
Retching or vomiting when you cough |
0 |
1 |
2 |
3 |
4 |
5 |
Cough on first lying down or bending over |
0 |
1 |
2 |
3 |
4 |
5 |
Chest tightness or wheeze when coughing |
0 |
1 |
2 |
3 |
4 |
5 |
Heartburn, indigestion, stomach acid coming up (or do you take medications for this, if yes score 5) |
0 |
1 |
2 |
3 |
4 |
5 |
A tickle in your throat, or a lump in your throat |
0 |
1 |
2 |
3 |
4 |
5 |
Cough with eating (during or soon after meals) |
0 |
1 |
2 |
3 |
4 |
5 |
Cough with certain foods |
0 |
1 |
2 |
3 |
4 |
5 |
Cough when you get out of bed in the morning |
0 |
1 |
2 |
3 |
4 |
5 |
Cough brought on by singing or speaking (for example, on the telephone) |
0 |
1 |
2 |
3 |
4 |
5 |
Coughing more when awake rather than asleep |
0 |
1 |
2 |
3 |
4 |
5 |
A strange taste in your mouth |
0 |
1 |
2 |
3 |
4 |
5 |
TOTAL SCORE_____________ /70