Salyva Oral Hydration Screening Questionnaire Form Do you feel dry mouth during meals? Yes No Do you have difficulty swallowing food? Yes No Do you percieve small amount of saliva in your mouth most of the time? Yes No Do you feel dry mouth at night, or upon waking? Yes No Do you feel dry mouth during the day? Yes No Do you chew gum, or mints to relieve the sensation of dry mouth? Yes No Do you frequently wake up thirsty at night? Yes No Do you have a burning sensation on your tongue? Yes No
