REFLUX REVIEW
Take this simple test to get a picture of how your symptoms affect your life.
1.How often do you have symptoms of heartburn or reflux?
Weekly
2–3 times a week
Every day
More than once a day
2.How long have you been experiencing these symptoms?
____weeks____ months ____ years (write the actual number, only to fill in one option)
3. Would you describe your symptoms as
Annoying but manageable
Uncomfortable
Painful
4.The symptoms you most often experience are (please indicate all that apply)
Burning feeling
Regurgitation
Acid or bitter taste in mouth
Sudden excess saliva
Burping
Chest pain
Sore throat
Difficulty swallowing
5.Do you avoid certain foods because of your symptoms?
Yes
No
6.Do you avoid certain activities you like to do because of your symptoms?
Yes
No
7.Do your symptoms interfere with your sleep?
Yes
No
8.Do you currently take any medication to manage your symptoms?
Yes
No
9.Are your symptoms relieved by medications?
Completely
For a short time
Improved, but some symptoms remain
Not at all
10.Are you finding that your medication isn’t working as well as it used to?
Yes
No
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