GERD-Q Questionnaire
Please answer the following questions to help assess your gastroesophageal reflux symptoms.
Full Name
*
First Name
Last Name
Age
*
Email Address
*
example@example.com
How often did you have a burning feeling behind your breastbone (heartburn) in the past week?
*
0 days
1 day
2-3 days
4-7 days
How often did you have stomach contents (liquid or food) moving upwards to your throat or mouth (regurgitation) in the past week?
*
0 days
1 day
2-3 days
4-7 days
How often did you have pain in the center of the upper stomach in the past week?
*
0 days
1 day
2-3 days
4-7 days
How often did you have nausea in the past week?
*
0 days
1 day
2-3 days
4-7 days
How often did you have trouble sleeping at night because of heartburn or regurgitation in the past week?
*
0 days
1 day
2-3 days
4-7 days
How often did you need to take additional medication for your symptoms (other than what your doctor told you to take) in the past week?
*
0 days
1 day
2-3 days
4-7 days
Please rate the overall impact of your symptoms on your daily activities in the past week.
*
No impact
1
2
3
4
Severely impacted
5
1 is No impact, 5 is Severely impacted
Do you have a history of GERD diagnosis?
*
Yes
No
Not sure
Additional Comments (Optional)
Submit Questionnaire
Should be Empty: