Patient Form

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

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


(select one)

All fields with an asterisk (*) are required.

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2020-CAP-Henrico Doctors-GERD Questionnaire-PHI
How satisfied are you with your current condition?
Do you experience regurgitation (contents refluxing into esophagus) when laying down?
Are you currently taking any medications for heartburn or GERD?
Are you concerned with the warnings regarding long-term heartburn medication use?
How would you like for us to follow up with you?