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Reflux Symptoms Index

Reflux Symptoms Index

"*" indicates required fields

Name*
DD slash MM slash YYYY

Within the last month, to what degree did the following problems affect you?

Hoarseness or a problem with your voice*
Clearing of your throat*
Excess throat mucus or postnasal drip*
Difficulty swallowing food, liquids, or pills*
Coughing after you eat or after lying down*
Breathing difficulties or choking episodes*
Troublesome or annoying cough*
Sensation of something sticking in your throat or a lump in your throat*
Heartburn or chest pain*