Postoperative Reflux Assessment Form
Use this form to review postoperative reflux symptoms, recovery context, and any follow-up needs. Please complete each item as accurately as possible.
Patient and Surgery Context
Patient Name
*
First Name
Last Name
Surgery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery / Procedure
*
Please Select
Fundoplication
Hiatal Hernia Repair
Bariatric Surgery
Esophageal Surgery
Other
Postoperative Day / Week Since Surgery
*
Reflux Assessment
Current reflux symptom severity
*
None
1
2
3
4
Very severe
5
1 is None, 5 is Very severe
Frequency of reflux episodes
*
Never
Occasional
Weekly
Daily
Symptoms since surgery
*
Improving
Unchanged
Worsening
Associated symptoms
Heartburn
Regurgitation
Nausea
Throat irritation
Difficulty swallowing
Chest discomfort
Other
Care Follow-up
Current reflux medication or treatment
Would you like a follow-up contact or appointment recommendation?
*
Yes
No
Additional comments or concerns
Submit
Should be Empty: