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Which describes your experience over the past 2 weeks?
How bad is your heartburn?
Do you have heartburn when lying down?
Do you have heartburn when standing up?
Do you have heartburn after meals?
Does your heartburn change your diet?
Does your heartburn wake you from sleep?
Do you feel pain when swallowing?
If you take reflux medication, does this affect your daily life?
How bad is your regurgitation?
Do you have regurgitation when lying down?
Do you have regurgitation when standing up?
Do you have regurgitation after meals?
Does your regurgitation change your diet?
Does your regurgitation wake you from sleep?
Do you have hoarseness or a problem with your voice?
Do you regularly have to clear your throat?
Do you have excess throat mucus or postnasal drip?
Do you have difficulty swallowing foods, liquids, or pills?
Do you suffer from coughing after you've eaten or after lying down?
Do you have breathing difficulties or choking episodes?
Do you have a troublesome or annoying cough?
Do you have the sensation of something sticking or a lump in your throat?
Do you suffer from heartburn, chest pain, indigestion, or stomach acid coming up?
(0) No symptoms
Incapacitating (5)
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