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Reflux Quiz
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Home
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Health First Reflux
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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
Next
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
Back
Next
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
Back
Next
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
Back
Next
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
Back
Next
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
Back
Next
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
Back
Next
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
Back
Next
Are you currently taking any medications for heartburn, reflux or GERD?
a.
Yes
b.
No
If so, what medications are you currently taking?
*
How long have you been taking the medications?
*
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