Prevalence of Eating and Swallowing problems in Young People

This survey is trying to determine how frequently people have problems swallowing food and liquid. The survey is anonymous and we will have no way of contacting you in the future. The survey is based on a Questionnaire developed by researchers in the USA, and asks 10 questions about your swallowing. We have also included a few questions to help the study team investigate the differences between different parts of the world.

The survey should only take a couple of minutes.
Demographic Questions

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* 1. Age

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* 2. Gender

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* 4. Nationality

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* 5. Medication

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* 6. Previous Medical Problems

Eating and Drinking

Please circle the appropriate response. To what extent are the following scenarios problematic for you?
0 = No Problem 4 = Severe Problem

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* 7. My swallowing problem has caused me to lose weight

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* 8. My swallowing problem interferes with my ability to go out for meals

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* 9. Swallowing liquids takes extra effort

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* 10. Swallowing solids takes extra effort

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* 11. Swallowing pills takes extra effort

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* 12. Swallowing is painful

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* 13. The pleasure of eating is affected by my swallowing

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* 14. When I swallow food sticks in my throat

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* 15. I cough when I eat

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* 16. Swallowing is stressful

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* 17. I have altered my diet because of my swallowing problem

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* 18. I am afraid to eat becasue of my swallowing problem

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* 19. I avoid eating in front of other people

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* 20. I get tired when I eat

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* 21. Do you have any other comments?

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