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Reflux Severity Index (RSI )

How to complete this Questionnaire:

  • These are statements many people have used to describe their voices and the effects of their voices on their lives
  • In the last 1 month, how did the following problems affect you?
  • Select the rating number that reflects the severity of the problem for you, for each statement.
0 - 5 Rating Scale
0 = no problem
1 = Very mild problem
2 = Moderate or slight problem
3 = Moderate problem
4 = Severe problem
5 = Problem as bad as it can be
Hoarseness or a problem with your voice
Clearing your throat
Excess throat or mucous post-nasal drip
Difficulty swallowing food, liquids or pills
Coughing after you ate or after lying down
Breathing difficulties or choking episodes
Troublesome or annoying cough
Sensations of something sticking in your throat
Heartburn, chest pain, indigestion, or stomach acid coming up

First Name
Surname
DOB
Email
Phone number
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Time is Up!

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