How often do you have heartburn
Never
Rarely
1-2 days a week
Most days
Every day
How often do you experience a burning sensation in your throat or a bitter or acidic taste in your mouth?
Never
Rarely
1-2 days a week
Most days
Every day
How often do you experience indigestion?
(Discomfort and pain in the upper abdomen and chest, often accompanied by feeling too full, bloating, belching)
Never
Rarely
1-2 days a week
Most days
Every day
How often do you have difficulty or pain when swallowing?
Never
Rarely
1-2 days a week
Most days
Every day
How often do you use over-the-counter antacids or prescription medication to treat these symptoms?
Never
Rarely
1-2 days a week
Most days
Every day
Your Risk For GERD
First Name
Last Name
Email
Phone Number
Have you seen a specialist for this condition?
Yes
No
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