GERD Screening Tool

Please answer the following questions on a scale of 0-5

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 activity

NAME:

EMAIL:

PHONE:

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 while lying down?

Regurgitation while standing up?

Regurgitation after meals?

Does regurgitation change your diet?

Does regurgitation wake you from sleep?

How satisfied are you with your current condition?Satisfied Neutral Dissatisfied