Mayo Dysphagia Questionnaire – 2 WEEK

Thank you for your willingness to participate in this important study.

Please focus on your symptoms over the past 2 weeks (14 days).

Directions: Answer each question as best as you can by the checking the appropriate response.

1.In the past 2 weeks, have you had trouble swallowing, not associated with other cold symptoms (such as strep throat or mono)?

1 Yes-please see below

2 No-please go to question number 9

2.When in your life did you first notice trouble swallowing?

1 Less than 1 month ago

2 1 to 3 months ago

3 3months to 1 year ago

4 1 year to 5 years ago

5 More than 5 years ago

6 I don’t know/remember

3.How would you rate the severity of your trouble swallowing over the past 2 weeks?

1 Doesn’t bother me at all

2 Mild – can be ignored if I don’t think about it

3 Moderate – cannot be ignored, but does not affect my lifestyle

4 Severe – affects my lifestyle

5 Very severe – markedly affects my lifestyle

6 I don’t know/remember

  1. How often have you had difficulty swallowing in the past 2 weeks?

1 None

2 Less than once a week

3 Once a week

4 Several times a week

5 Daily

6 With every meal

7 With each swallow

8 Unable to eat

5.Which statement best describes you? (Mark only one.)

1 I have problems swallowing liquids only.

2 I have problems swallowing solid foods only.

3 I have problems swallowing solid foods, and I have problems with liquids only after other solid food is stuck.

4 I have problems swallowing both liquids and solid foods.

6.In the past 2 weeks, have you avoided any of the following types of foods to avoid food getting stuck?

(Mark yes or no for all)

Fiber - foods like meat, chicken, bread, celery, salad11 Yes 21 No

Softsolids - like oatmeal, applesauce, pudding, soup12 Yes 22 No

Liquids - like water, juice, soda, coffee or tea?13 Yes 23 No

  1. In the past 2 weeks, have you had trouble swallowing any of these foods or other foods like them?

(Mark yes or no for all)

Oatmeal (or other foods, like grits, cream of wheat, rice)11 Yes 21 No

Banana (or other foods, like pudding, Jello)12 Yes 22 No Apple (or other foods with fiber, such as celery) 13 Yes 23 No

Ground meat (like hamburger or ground turkey)14 Yes 24 No

Bread (or other foods, like cake, doughnuts, muffins)15 Yes 25 No

Meat (fibrous meats, like steak or chicken) 16 Yes 26 No

8.Compared to other people around you in the past 2 weeks, at what pace do you eat a meal?

1 At the same speed

2 A little slower

3 Much slower

9.In the past 2 weeks, have you ever had solid food (not including medications) stick in your swallowing tube for over five minutes?

1 Yes

2 No

10.Has it been painful to swallow in the past 2 weeks?

1 Yes

2 No

11.In the past 2 weeks, have you experienced heartburn, a burning pain or discomfort behind the breast bone in the chest?

1 Yes-please see below

2 No-please go to question number 18

12.When in your life did you first notice the heartburn?

1 Less than 1 month ago

2 1 to 3 months ago

3 3 months to 1 year ago

4 1 year to 5 years ago

5 More than 5 years ago

6 I don’t know/remember

13.In the past 2 weeks, how frequently have you noticed heartburn?

1 Less than once a week

2 About once a week

3 2 to 5 times a week

4 More than once a day

5 I don’t know/remember

14.How would you rate the severity of your heartburn over the past 2 weeks?

1 Doesn’t bother me at all

2 Mild – can be ignored if I don’t think about it

3 Moderate – cannot be ignored, but does not affect my lifestyle

4 Severe – affects my lifestyle

5 Very severe – markedly affects my lifestyle

6 I don’t know/remember

15.Is your heartburn made better (eased) by taking antacids? Examples: Amphojel,Alternagel, Gaviscon, Maalox, Mylanta, Riopan, Rolaids, Tums.

1 I do not take antacids for heartburn

2 Yes

3 No

16.In the past 2 weeks, has your heartburn awakened you at night?

1 Yes

2 No

17.In the past 2 weeks, has your heartburn often traveled up toward your neck?

1 Yes

2 No

18.In the past 2 weeks, have you experienced acid regurgitation, a bitter or sour-tasting fluid coming up from the stomach into your mouth or throat?

1 Yes - please see below

2 No - please go to question number 22

19.When in your life did you first notice the acid regurgitation?

1 Less than 1 month ago

2 1 to 3 months ago

3 3 months to 1 year ago

4 1 year to 5 years ago

5 More than 5 years ago

6 I don’t know/remember

20.In the past 2 weeks, how frequently have you noticed acid regurgitation?

1 Less than once a week

2 About once a week

3 2 to 5 times a week

4 More than once a day

5 I don’t know/remember

21.How would you rate the severity of your acid regurgitation over the past 2 weeks?

1 Doesn’t bother me at all

2 Mild – can be ignored if I don’t think about it

3 Moderate – cannot be ignored, but does not affect my lifestyle

4 Severe – affects my lifestyle

5 Very severe – markedly affects my lifestyle

6 I don’t know/remember

22.Have you ever been diagnosed with seasonal or environmental (food, dogs, cats, cows,horses, weeds, mold, pollen) allergies?

1 Yes

2 No

23.Have you ever been told by a doctor (or other health professional) that you have asthma?

1 Yes

2 No

The following questions ask about your use of prescription and over-the-counter medicines over the past2 weeks (14 days).

24.Have you taken antacids in the past 2 weeks? Examples: Amphojel, Alternagel, Gaviscon,Maalox, Mylanta, Riopan, Rolaids, Tums.

1 Yes

2 No

25.Have you taken any of the following medicines in the past 2 weeks?

Axid (nizatidine), Carafate (sucralfate), Pepcid (famotidine), Tagamet (cimetidine), Zantac (ranitidine).

1 Yes

2 No

26.Have you taken any of the following medicines in the past 2 weeks?

Aciphex (rabeprazole), Nexium (esomeprazole), Protonix (pantoprazole), Prevacid(lansoprazole), Prilosec, Prilosec OTC or Zegerid (omeprazole).

1 Yes

2 No

In the past 2 weeks, have you had any of the following surgical treatments or procedures for esophageal disease?

27.A part of my stomach was wrapped around the end of my esophagus (Nissen or Belsey fundoplication).

1 Yes

2 No

3 Unsure

28.Part of my esophagus was removed.

1 Yes

2 No

3 Unsure

29.Dilation (stretching) of the esophagus.

1 Yes

2 No

3 Unsure

Thank you for completing this questionnaire.

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