GERD HEALTH-RELATED QUALITY OF LIFE (GERD-HRQOL) QUESTIONNAIRE

PATIENT DETAILS

First Name *

Last Name *

Email Address *

Scale:
0 = No Symptoms
1 = Noticeable, but not bothersome
2 = Noticeable, bothersome, but not every day
3 = Bothersome daily
4 = Bothersome and affects daily activities
5 = Incapacitating to do daily activities

QUESTIONS (PLEASE SELECT ONE):

How bad is the heartburn? *

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Heartburn when lying down? *

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Heartburn after meals? *

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Heartburn when standing up? *

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Does heartburn change your diet? *

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Does heartburn wake you from sleep? *

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Do you have difficulty swallowing? *

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Do you have pain while swallowing? *

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Do you have gassy or bloating feeling? *

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If you take reflux medication, does this affect your daily life? *

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Your Score (out of 50)

Additional Questions

How bad is the regurgitation? *

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Regurgitation when lying down? *

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Regurgitation when standing up? *

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Regurgitation after meals? *

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Does regurgitation change your diet? *

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Does regurgitation wake you from sleep? *

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How satisfied are you with your current health condition? *

SatisfiedNeutralDissatisfied

Are you currently taking any medications for heartburn or GERD? *

YesNo

Please select any of the medications you have taken in the past or are currently taking: *

Esomeprazole (Nexium)Lansoprazole (Prevacid)Omeprazole (Prilosec/Zegerid)Pantoprazole (Protonix)Rabeprazole (Aciphex)None

NP02165-01D: Velanovich V (2007) The development of the GERD-HRQL symptom severity instrument. Diseases of the Esophagus 20:130-134

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