Bayside Voice Centre
(07) 3193 5436

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Certified Practising Speech Pathologist, Cleveland

Reflux Symptom Index (RSI)

These are statements that many people have used to describe their voices and the effects of their voices on their lives.  Select the response that indicates how frequently you have had the same experience in the last 4 weeks.  If you do not have a problem with reflux, please select zero (0) in response to these questions.

0 = Never
1 = Almost Never
2 = Sometimes
3 = Almost Always
4 = Always

The results of these questions will be sent to your Speech Pathologist who will discuss them with you at your next appointment.

NB:  Before completing this form, please ensure that you have made an appointment with Jenny Matthews, through Redlands Specialist Centre, (07) 3193 5436. These forms are specifically designed for patients to complete prior to their initial assessment and after you have made an appointment, you will be advised which forms are necessary for you to complete, depending on the reason for your appointment. Because these forms do not collect your contact information, if you complete these forms before making an appointment we will have no way of contacting you to discuss the results. 

0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
0 = Never / 1 = Almost never / 2 = Sometimes / 3 = Almost always / 4 = Always
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Belafsky, P. C., Postma, G. N., & Koufman, J. A. (2002). Validity and reliability of the reflux symptom index (RSI). J Voice, 16(2), 274-277.