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?
Heartburn after meals?
Does heartburn change your diet?
Does heartburn wake you from sleep?
Do you have difficulty swallowing?
Do you have gassy or bloating feeling?
How bad is the regurgitation?
Regurgitation after meals?
TOTAL SCORE
(enter total here; 45 points total)
How satised are you with your current health condition?
Are you currently taking any medications for heartburn or GERD?
Please select any of the medications you have taken in the past or are currently taking:
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