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> Reflux Symptoms Index
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Reflux Symptoms Index
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Reflux Symptoms Index
Name
*
First
Last
Date of Birth
*
Date
*
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
*
0
1
2
3
4
5
Clearing of your throat
*
0
1
2
3
4
5
Excess throat mucus or postnasal drip
*
0
1
2
3
4
5
Difficulty swallowing food, liquids, or pills
*
0
1
2
3
4
5
Coughing after you eat or after lying down
*
0
1
2
3
4
5
Breathing difficulties or choking episodes
*
0
1
2
3
4
5
Troublesome or annoying cough
*
0
1
2
3
4
5
Sensation of something sticking in your throat or a lump in your throat
*
0
1
2
3
4
5
Heartburn or chest pain
*
0
1
2
3
4
5
Δ
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