Don't ignore your pain or discomfort. Complete this brief self-assessment to determine if you might benefit from therapeutic intervention.
|Mild symptoms; not easy to recognize||2|
|Significant symptoms; can be endured||3|
|Serious symptoms; affect daily life||4|
|Very serious symptoms; significantly affects daily functions||5|
|No symptoms in the past one year||1|
|Less than once a month||2|
|At least once a month||3|
|At least once a week||4|
|At least once a day||5|
|Severity (1–5)||Frequency (1–5)|
|Within the past 12 months, have you experienced any of the following symptoms: heartburn, chest burn, chest pain, coughing, voice transformation, hoarseness, uncomfortable feelings radiating from the chest to the throat, constant earache or sinusitis?|
|Within the past 12 months, have you ever had gastric acid reflux?|
|Within the past 12 months, have you ever had gastric acid reflux coming up to your throat?|
|In the past 12 months, how many times did you take antacids or other medicines for stomach ailments?|
If your total score (severity and frequency) is 12 or more, contact the Heartburn and Reflux Center at 775-352-5384 to schedule a consultation.