Today's Date
* *
Date of Birth

To answer questions 1-15 please use the following scale:

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 activity

5 = Symptoms are incapacitating to do daily activities

How bad is the heartburn?*
Heartburn when lying down?*
Heartburn when standing up?*
Heartburn after meals?*
Does heartburn change your diet?*
Does heartburn wake you from sleep?*
Do you have difficulty swallowing?*
Do you have pain with swallowing?*
If you take medication, does this affect your daily life?*
How bad is the regurgitation?*
Regurgitation when lying down?*
Regurgitation when standing up?*
Regurgitation after meals?*
Does regurgitation change your diet?*
Does regurgitation wake you from sleep?*
How satisfied are you with your present condition?
Do you take any of the following medication?