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
All fields with an asterisk (*) are required.
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