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