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Reflux Quiz
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Health First | Brevard County FL | Health Insurance Plans | Space Coast Healthcare Provider | Hospital Services
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Health First Reflux
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How long have you had acid reflux?
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
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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 or pain when 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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