Dysphagia Assessment Survey
Please answer the following questions to help assess swallowing difficulties.
Full Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you experience difficulty swallowing solids?
Never
Rarely
Sometimes
Often
Always
Do you experience difficulty swallowing liquids?
Never
Rarely
Sometimes
Often
Always
Do you cough or choke when eating or drinking?
Never
Rarely
Sometimes
Often
Always
Do you experience pain while swallowing?
Never
Rarely
Sometimes
Often
Always
Have you noticed any weight loss recently?
Yes
No
Additional comments or concerns
Submit
Should be Empty: