• Please use the following scale to complete questions 1 through 30.

    0 = No symptoms
    1 = Symptoms noticeable but not bothersome
    2 = Symptoms noticeable and bothersome every day
    3 = Symptoms bothersome every day
    4 = Symptoms affect daily activities
    5 = Symptoms are incapacitating, unable to do activities
  • Medication Use

    Do you take any medications for your reflux symptoms?
  • This field is for validation purposes and should be left unchanged.