Patient Information Form

ACID REFLUX (GERD)RISK ASSESSMENT

Did you know that:

33% of people in the United States, suffer from acid reflux
Acid Reflux is linked to asthma, voice disorders, and Barrett's Esophagus which increases your risk of esophageal cancer
Acid Reflux significantly interrupts your ability to sleep soundly through the night
Acid Reflux can affect people of all ages ranging from babies to adults

Do you have Acid Reflux? Yes=2 points, Occasionally=1 point, No=0 points

Full Name

First NameLast Name

Phone Number

Area CodePhone Number

Do you smoke?

1. Are you more than 10% above your ideal body weight?

2. Do you experience frequent heartburn or chest pains (primarily after eating)?

3. Do you have difficulty breathing or swallowing?

4. Do you feel as if there is a constant lump in your throat?

5. Do you experience regurgitation?

6. Do you experience post-nasal drip or excess throat mucus?

7.Do you suffer from a chronic cough?

8. Do you experience frequent choking episodes?

9. Do you suffer from indigestion, burping, nausea after eating, or stomach bloating?

10. Do you feel hoarseness in your throat primarily in the mornings?

11. Do you have heart burn (esophageal reflux or GERD)?

Score total points:

0-3 Unlikely for active disease: learn more about prevention

4-6 low suspicion of active disease inflammation: seek consultation

7-10 moderate suspsicion of active disease: seek consultation

12+ high suspicion of active disease: get immediate attention