Barrett’s Esophagus Risk Assessment Questionnaire Form
Please complete this assessment to help estimate your risk factors and symptoms related to Barrett’s esophagus. All responses are confidential and no sensitive personal identifiers are collected.
What is your age range?
*
Please Select
Under 30
30-39
40-49
50-59
60 or older
What is your biological sex?
*
Male
Female
How often do you experience heartburn or acid reflux?
*
Never
Rarely (less than once a month)
Sometimes (monthly)
Often (weekly)
Very often (daily)
How many years have you experienced symptoms of heartburn or acid reflux?
*
Please Select
Less than 1 year
1–5 years
6–10 years
More than 10 years
Do you currently smoke or have you smoked in the past?
*
Never smoked
Former smoker
Current smoker
How often do you consume alcoholic beverages?
*
Never
Occasionally (less than once a week)
Regularly (1–3 times per week)
Frequently (4 or more times per week)
Have you ever had a family member diagnosed with Barrett’s esophagus or esophageal cancer?
*
Yes
No
Not sure
Please indicate the severity of the following symptoms in the past month:
*
Rows
None
Mild
Moderate
Severe
Difficulty swallowing
1
2
3
4
Chest pain
5
6
7
8
Regurgitation of food or sour liquid
9
10
11
12
Chronic cough
13
14
15
16
How would you rate your overall digestive comfort over the past month?
*
1
2
3
4
5
Is there anything else you would like to share about your symptoms or risk factors?
Submit Assessment
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