LPR Chronic Cough Assessment Form
Assess chronic cough patterns, possible LPR-related symptoms, triggers, and prior treatment history. This form is designed for symptom tracking and screening context, not for collecting sensitive health information.
Respondent & Symptom Overview
Age range
*
Under 18
18–24
25–34
35–44
45–54
55–64
65+
How long have you had the cough?
*
Please Select
Less than 3 months
3–6 months
6–12 months
1–2 years
More than 2 years
How often do you cough?
*
Please Select
Occasionally
Several times a day
Hourly
Most of the day
Nearly constant
Cough severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Type of cough
*
Dry
Productive
Both
LPR Symptom Pattern & Triggers
When does your cough usually occur?
*
Morning
After meals
When lying down
Nighttime
Throughout the day
Other
How often do you experience the following symptoms?
*
Rows
Never
Rarely
Sometimes
Often
Always
Throat clearing
1
2
3
4
5
Sour or bitter taste
6
7
8
9
10
Hoarseness
11
12
13
14
15
Throat irritation
16
17
18
19
20
Globus sensation
21
22
23
24
25
What seems to trigger or worsen your symptoms?
Spicy foods
Caffeine
Late meals
Alcohol
Lying down after eating
Voice use
Other
Prior Evaluation, Treatments & Goal
Previously evaluated for this cough?
*
Yes
No
Past treatments tried
Reflux medication
Antacids
Lifestyle changes
Cough suppressants
Allergy treatment
Voice rest
Other
Submit Assessment
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