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Reflux Symptom Index (RSI)
Within the last month, how did the following problems affect you?
(0-5 rating scale with 0=No problem and 5=Severe)
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* Indicates required question
What is your name?
*
Your answer
1. Hoarseness or a problem with your voice
*
No problem
0
1
2
3
4
5
Severe
2. Clearing your throat
*
No problem
0
1
2
3
4
5
Severe
3. Excess throat mucous or postnasal drip
*
No problem
0
1
2
3
4
5
Severe
4. Difficulty swallowing food, liquids or pills
*
No problem
0
1
2
3
4
5
Severe
5. Coughing after you ate or after lying down
*
No problem
0
1
2
3
4
5
Severe
6. Breathing difficulties or choking episodes
*
No problem
0
1
2
3
4
5
Severe
7. Troublesome or annoying cough
*
No problem
0
1
2
3
4
5
Severe
8. Sensation of something sticking in your throat
*
No problem
0
1
2
3
4
5
Severe
9. Heart burn, chest pain, indigestion, or stomach acid coming up
*
No problem
0
1
2
3
4
5
Severe
Belafsky PC, Postma GN, and Koufman JA. Validity and reliability of the reflux symptom index(RSI). Journal of Voice. 2002. 16(2): 274-277.
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