Heartburn & Reflux Center Questionnaire

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.
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
FemaleMale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Idaho FallsBlackfootPocatello
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
DailyA Few Times a WeekOcassionallyRarely or Never
YesNo
OftenSometimesRarelyNever
YesNo
YesNo
YesNo
Not at AllSlightlyModeratelySeverley
Section 2: Current Management
Yes - Over-the-Counter (Antacids, H2 Blockers, PPIs)Yes - PrescriptionNo
YesNo
Should be Empty:

Heartburn & Reflux Symptom Questionnaire