1.	Do you experience difficulty chewing solid food like apple, cookie, or cracker?	0	1	2	3
2.	Are there any food residues in your mouth, cheeks, under your tongue, or stuck to the roof of your mouth after swallowing?	0	1	2	3
3.	Does food come out of your nose or mouth when you eat or drink?	0	1	2	3
4.	Does chewed up food dribble from your mouth?	0	1	2	3
5.	Do you feel you have too much saliva in your mouth (do you drool or have difficulty in swallowing your saliva)?	0	1	2	3
6.	Do you swallow chewed up food several times before it goes down your throat?	0	1	2	3
7.	Do you experience difficulty in swallowing solid food (do apples or crackers get stuck in your throat)?	0	1	2	3
8.	Do you experience difficulty in swallowing pureed food?	0	1	2	3
9.	While eating, do you feel as if a lump of food is stuck up in your throat?	0	1	2	3
10.	Do you cough while swallowing liquids?	0	1	2	3
11.	Do you cough while swallowing solid food?	0	1	2	3
12.	Immediately after eating or drinking, do you experience a change in your voice, such as hoarseness or wetness?	0	1	2	3
13.	Other than during meals, do you experience coughing or difficulty in breathing as a result of saliva entering your windpipe?	0	1	2	3
14.	Do you experience difficulty in breathing during meals?	0	1	2	3
15	Have you suffered from respiratory infection (such as pneumonia, bronchitis) in the past years? (circle one)	Yes		No