Questionnaire choking - (copy)

Questionnaire, English and Japanese, to gauge choking incidents and followup and outcome and comments

A red asterisk (*) indicates required questions.

  1. Have you ever felt like you were choking?

    not sure

  1. When did the choking incident take place?

    while eating a meal
    while eating a snack
    while drinking a beverage
    other - describe

  1. What were you doing at the time?
    eating and walking
    eating and talking
    eating and drinking (non-alcoholic beverage)
    eating and drinking (alcoholic beverage)
    eating and drinking and laughing at a party or reunion
    eating sitting at the table alone
    eating fast food, not talking, not laughing, alone
    other - explain

  1. What did you choke on?
    potato or vegetable
    pasta al dente
    konnyaku (oden)
    konnayaku (with fruit flavor)
    bread, roll or muffin
    custera, cake,
    salad, raw vegetables
    other - describe

  1. When did you choke?
    New Year celebration family reunion
    Other celebration (no alcohol)
    Other celebration (alcohol)
    Other - describe

  1. What is your age, please?
    101 plus

  1. What is your eating style?
    Usually eat fast
    Usually eat slowly
    Usually eat alone
    Usually eat with other people
    Other - describe

  1. What do you think caused your feeling of choking?
    Eating too fast
    Not chewing before swallowing
    Paying attention to talking not eating

  1. Do you wear dentures or dental fixtures?
    wear upper plate
    wear lower plate
    wear both
    wear bridge
    wear more than one bridge
    other - describe

  1. Do your dentures fit properly?
    Dentures are too tight
    Dentures are too loose
    Have lost weight recently
    Dentures hurt when chewing
    Other - describe

  1. How long have you worn dentures?
    1-2 years or less
    3-5 years
    6-20 years
    21 years and more
    other - describe

  1. When you felt that you were choking, what did you do?
    drank some liquid
    started coughing
    stood up from the table
    other - describe

  1. What helped to stop the choking?
    drank some liquid
    started coughing
    stood up from the table
    other - describe

  1. Were you frightened?
    don't remember
    other- desribe

  1. Did anyone come to your help?
    friend slapped back
    friend got vacuum cleaner
    other - describe

  1. What is the international sign for choking?
    Hand at throat
    other - describe

  1. If you are choking, and water or coughing does not help, what can you do?
    call for help
    use the back of a chair to press in the diaphragm
    use the side of a bathtub
    use the edge of a kitchen counter
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