First Name
Last Name
Phone
Email
How bad is your heartburn?
How bad is your heartburn?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Heartburn when lying down?
Heartburn when lying down?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Heartburn when standing up?
Heartburn when standing up?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Heartburn after meals?
Heartburn after meals?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Does heartburn change your diet?
Does heartburn change your diet?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Does heartburn wake you from sleep?
Does heartburn wake you from sleep?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Do you have difficulty swallowing?
Do you have difficulty swallowing?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Do you have pain with swallowing?
Do you have pain with swallowing?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
Do you have bloating or gassy feelings?
Do you have bloating or gassy feelings?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
If you take medications, does this affect your daily life?
If you take medications, does this affect your daily life?
0 - No symptoms
1 - Symptoms noticeable, but not bothersome
2 - Symptoms noticeable and bothersome, but not every day
3 - Symptoms bothersome every day
4 - Symptoms affect daily activities
5 - Symptoms are incapacitating, unable to do daily activities
How satisfied are you with your present condition?
How satisfied are you with your present condition?
Satisfied
Neutral
Dissatisfied
Are you currently taking any medications for heartburn or GERD?
Medications
