REFLUX SYMPTOM INDEX (RSI) QUESTIONNAIRE

PATIENT DETAILS

First Name *

Last Name *

Email Address *

Within the last month, how did the following problems affect you?

Select the appropriate number that best applies to your symptoms.

0 = No Problem
5 = Severe Problem

QUESTIONS (PLEASE SELECT ONE):

SCORE

SCORE1

Adapted from:

Reflux Symptom Index (RSI)University of Iowa Health Carehttps://medicine.uiowa.edu/iowaprotocols/reflux-symptom-index-rsiBelafsky PC, Postma GN, Koufman JA. Validity and reliabiltiy of the reflux symptom index (RSI). Journal of Voice 2002, 16(2):274-277

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