GERD Questionnaire Form

  • Patient Form

    If you have heartburn/GERD or take medication for those conditions, please complete this 10-question GERD Health Related Quality of Life (HRQL)

    0 = No Symptoms
    1 = Symptoms noticeable, but not bothersome
    2 = Symptoms noticeable and bothersome, but not every day
    3 = Symptoms bothersome every day
    4 = Symptoms affect daily activities
    5 = Symptoms are incapacitating, unable to do daily activities

  • Questions

    Select one