• Heartburn & Reflux Symptom Questionnaire

    Once you submit this form, we will review your information. Our team will then contact you to schedule your appointment and discuss next steps.
  • Birth Date*
     - -
  • Gender*
  • Format: (000) 000-0000.
  • Preferred Clinic Location*

  • Some Medicare Advantage plans may require prior authorization and/or a referral from your primary care provider before specialty services will be covered.

  • Section 1: Symptom Check

  • How often do you experience heartburn (a burning sensation in your chest)?*
  • Do you ever experience a sour taste in your mouth or the sensation of acid backing up into your throat?*
  • Do you have difficulty swallowing food or feel like food gets stuck in your throat?*
  • Do you have a chronic cough, hoarseness, or frequent throat clearing not related to a cold?*
  • Do your symptoms worsen after meals or when lying down?*
  • Do you wake up at night due to heartburn or regurgitation?*
  • How much are your symptoms affecting your daily life or sleep?*

  • Section 2: Current Management

  • Are you currently taking any over-the-counter or prescription medications for heartburn or reflux?*
  • Have you ever been diagnosed with GERD (gastroesophageal reflux disease) or any other digestivecondition?*
  • Should be Empty: