Heart Burn/Acid Reflux Telemedicine Visit
  • Date of Birth*
     - -
  • What was your gender at birth?*

  • Format: (000) 000-0000.

  • TERMS OF SERVICE

  • *

  • Advanced Beneficiary Notice

    Patient is solely responsible for paying out-of-pocket the full charge for this visit. This service is not covered under Medicare or Medicaid. Omnia TeleHEALTH will not submit a bill to or request for payment from Medicare and Medicaid or any other payor. 

  • You should NOT use Omnia TeleHEALTH if you are experiencing an emergency. Emergencies include but are not limited to:

    • Severe or unusual chest pain
    • Severe shortness of breath
    • Symptoms of a stroke (such as facial drooping, arm weakness, or speech difficulties)
    • Thoughts of harming yourself or others
  • ARE YOU EXPERIENCING AN EMERGENCY? IF YOU ARE EXPERIENCING AN EMERGENCY, CALL 911 OR GO TO AN EMERGENCY ROOM IMMEDIATELY.*

  • Gastroesophageal reflux disease (GERD), also known as acid reflux, is a condition that occurs when stomach contents or stomach acid backs up into the esophagus (swallowing tube) or the mouth.

  • Which of the following applies to you?*

  • This visit is not intended for patients with chest pain. If you are currently experiencing chest pain, please go to an emergency room or call 911 immediately.

  • Are you currently experiencing chest pain?*

  • This visit does not guarantee a refill. The provider will determine whether a refill is apprpriate based on the responses.

  • How long have you taken this medication?*
  • Please select the option that best applies to you regarding the treatment.*
  • How long have you had acid reflux symptoms?*
  • How often do you usually experience symptoms?*
  • When did you last see a provider regarding GERD?*
  • Over the past 7 days, how often did you have a burning feeling behind the breastbone (heartburn)?*
  • Over the past 7 days, how often did you have stomach contents (liquid or food) moving upward to the throat of mouth (regurgitation)?*
  • Over the past 7 days, how often did you have pain in the center of the upper stomach?*
  • Over the past 7 days, how often did you have nausea?*
  • Over the past 7 days, how often did you have difficulty getting a good night's sleep because of heartburn and/or regurgitation?*
  • Over the past 7 days, how often did you need to take additional over-the-counter medication (such as Tums, Rolaids, Maalox) for the heartburn and/or regurgitation other than a medication a provider told you to take?*
  • Do you have any of the following symptoms? (Select ALL that apply)*
  • Please rate the severity of your abdominal pain on the following scale, with 0 being no pain and 10 being the worst pain imaginable.*

  • Where is the abdominal pain located? (Select ALL that apply)
  • Please describe your pain:*
  • When did your current episode of abdominal pain start?*
  • Is your stool dark or tar-colored?*
  • Have you noticed any blood in your stool?*
  • Do you have any of the following symptoms? (Select ALL that apply)*
  • In the last 3 months, have you had an unintentional weight loss of more than 10 pounds that is not due to increased exercise or dieting?*

  • GERD symptoms can be caused by or made worse by certain foods such as fried or spicy foods, caffeine, alcohol, and chocolate. GERD can improve with modifications to the diet.

  • Have you tried modifying your diet to treat the symptoms?*
  • Did the diet changes help your symptoms?*
  • Have you tried anything to help the current symptoms, such as over-the-counter or prescription medications?*
  • Which have you tried for the current GERD symptoms? (Select ALL that apply)*
  • Was the medication used for your GERD symptoms effective?*

  • MEDICAL HISTORY

  • Do you have any of the following conditions? (Select ALL that apply)*
  • Do you have any of the following heart conditions? (Select ALL that apply)*
  • Have you ever had bariatric surgery (gastric bypass, gastric sleeve, or other weight-loss surgery)?*
  • Have you ever had an upper endoscopy (a procedure during which a provider inserts a long, flexible tube with a camera at the end to examine the upper digestive tract)?*
  • Do you have any medication allergies?*
  • Are you currently taking any medications?*
  • Are you pregnant?*
  • Are you breastfeeding?*

  • PHARMACY INFORMATION

    Please choose where you would like your prescription sent
  • Would you like to add any additional information or questions for the provider to see?*

  • My Products*

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