Laryngopharyngeal Reflux Symptom Questionnaire Form
Please complete this concise survey to help us understand your symptoms related to laryngopharyngeal reflux. This is not a diagnostic tool and is for screening and symptom tracking only.
Your first and last name
*
First Name
Last Name
Your age
*
How often do you experience symptoms such as throat clearing, cough, or hoarseness?
*
Never
Rarely (less than once a week)
Sometimes (1-2 times a week)
Often (3-4 times a week)
Daily
Please rate the severity of your symptoms over the past two weeks.
*
No symptoms
0
1
2
3
4
5
6
7
8
9
Very severe
10
0 is No symptoms, 10 is Very severe
Which of the following symptoms have you experienced? (Select all that apply)
*
Frequent throat clearing
Hoarseness or voice changes
Chronic cough
Sensation of a lump in throat
Sore throat
Difficulty swallowing
Other
When do your symptoms most commonly occur?
*
Morning
Afternoon
Evening
During the night
No specific time
Have you noticed any triggers for your symptoms? (e.g., certain foods, activities, environments)
Have you previously been evaluated by a healthcare professional for these symptoms?
*
Yes
No
Are you currently using any treatments or management strategies for these symptoms?
*
Yes
No
Briefly describe how these symptoms affect your daily activities or quality of life.
Submit
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