Gastroesophageal reflux disease (GERD) can present a range of symptoms in different patients. Sometimes chronic reflux is easy to manage with diet or lifestyle changes. For others, the persistent reflux is disruptive or even painful, making everyday activities difficult. The best treatment depends in part of the severity of symptoms, and how disruptive they are to a patient’s lifestyle and overall sense of his or her quality of life.
To help guide your conversation with a physician, the following questionnaire has been developed especially for those living with GERD. Answer each question according to the scale provided below, then either print or share a copy of your results when you meet with your physician.
Information gathered from this form is used to understand symptom severity. In accordance with Federal HIPAA regulations, this data will not be linked to an individual’s personal identity.