Modern Review

GERD Health-Related Quality of Life (GERD-HRQL) Questionnaire

Scale: 0=No Symptoms 1=Noticeable, but not bothersome 2=Noticeable, bothersome, but not every day 3=Bothersome daily 4=Bothersome and affects daily activities 5=Incapacitating to do daily activities
QUESTIONS (Choose One):
How bad is the heartburn?

012345
Heartburn after meals?

012345
Does heartburn change your diet?

012345
Does heartburn wake you from sleep?

012345
Do you have difficulty swallowing?

012345
Do you have gassy or bloating feeling?

012345
How bad is the regurgitation?

012345
Regurgitation after meals?

012345
TOTAL SCORE
(enter total here; 45 points total)
How satised are you with your current health condition?

SatisfiedNeutralDissatisfied
Are you currently taking any medications for heartburn or GERD?

YesNo
Please select any of the medications you have taken in the past or are currently taking:

NexiumPrilosecPrevacidAciphexProtonixZegeridKapidexDexilantVimovo
Full Name:*

First NameMiddle NameLast Name
Phone Number:

Area CodePhone Number
Email:*
Email
Date:*

MonthDayYear
Date
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GERD Health-Related Quality of Life (GERD-HRQL) Questionnaire