Reflux Symptoms Index

Name*

First Last

Date of Birth*

Date*

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*

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