Heartburn & Reflux
Center of Northwest Ohio

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How may we help you?

How may we help you?

Heartburn & Reflux Center of Northwest Ohio Online Quiz

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


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 


1. How bad is your heartburn?  *

2. Heartburn when lying down?  *

3. Heartburn when standing up?  *

4. Heartburn after meals?  *

5. Does heartburn change your diet?  *

6. Does heartburn wake you from sleep?  *

7. Do you have difficulty swallowing?  *

8. Do you have pain with swallowing?  *

9. Do you have bloating or gassy feelings?  *

10. If you take medications, does this affect your daily life?  *

Total Score: How satisfied are you with your current condition?  *Do you experience regurgitation (contents refluxing when laying down or bending over)?  *Are you currently taking any medications for heartburn or GERD?  *If so, what are you currently taking? For how long? Are you concerned with the warnings regarding long-term heartburn medication use?  *First Name:  *Last Name:  *Phone Number:  *