Age
Gender
Education
Occupation
Do you smoke?
How many cigarettes per day?
Are you taking any medicines currently?
Name of Medicine
Suffering from any disease?
Which disease are you suffering from?
Do you feel dryness in your mouth?
I sip liquids to help swallow food.
My mouth feels dry when eating a meal
I get up at night to drink
My mouth feels dry
I have difficulty in eating dry foods
I suck sweets or cough lollies to relieve dry mouth
I have difficulties swallowing certain foods
The skin of my face feels dry
My eyes feel dry
My lips feel dry
The inside of my nose feels dry
Active XI Scale Total
Active XI Category
Recovered XI Scale Total
Recovered XI Category
Have you had trouble pronouncing any word?
Have you felt that your sense of taste has worsened?
Have you had painful aching in your mouth?
Have you found it uncomfortable to eat any foods?
Have you been self-conscious?
Have you felt tense?
Has your diet been unsatisfactory?
Have you had to interrupt meals?
Have you found it difficult to relax?
Have you been a bit embarrassed?
Have you been a bit irritable with other people?
Have you had difficulty doing your usual job?
Have you felt that life, in general, was less satisfying?
Have you been totally unable to function?
Active OHIQ Scale Total
Active OHIQ Category
Recovered OHIQ Scale Total