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 |
Excess mucus in the throat, or drip down the back of your nose | 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 during the day rather than night | 0 | 1 | 2 | 3 | 4 | 5 |
A strange taste in your mouth | 0 | 1 | 2 | 3 | 4 | 5 |
Total score_____________/70 |
This is self-administered and has 14 items. Responses to each question can vary from 0 to 5.