Eating Assessment Tool (EAT-10)

This is a standarized patient reported outcome measure, completed pre/post tx.

Name

Have you had previous swallow testing or treatment? Briefly, what were results?

Briefly describe your swallowing problem

please include your height and weight

Circle the number in each item that describes your swallowing 0- no problem 4- severe problem

My swallowing has caused me to lose weight.

My swallowing restricts my abilty to go out for meals.

Swallowing liquids takes extra effort.

Swallowing solids takes extra effort.

Swallowing pills takes extra effort.

Swallowing is painful.

The pleasure of eating is affected by my swallowing.

When I swallow, food sticks in my throat.

I cough when I eat.

Swallowing in stressful.

Please total your score

Pre or post score:

This is a pre-treatment score This is a post-treatment score

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