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GERD-HRQL Questionnaire



If you have heartburn or GERD, or take medications for those conditions, complete the GERD-HRQL (Health Related Quality of Life) questionnaire, print a copy with your answers and consult with a health care provider.

Scale:
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


  1. How bad is your heartburn?
  2. Heartburn when lying down?
  3. Heartburn when standing up?
  4. Heartburn after meals?
  5. Does heartburn change your diet?
  6. Does heartburn wake you from sleep?
  7. Do you have difficulty swallowing?
  8. Do you have pain with swallowing?
  9. Do you have bloating or gassy feelings?
  10. If you take medications, does this affect your daily life?
  11. How satisfied are you with your present condition?
  12. Are you currently taking any medications for heartburn or GERD?    

Please select any of the medications you have taken in the past or are currently taking:
Your Zip Code:   


Information gathered from this form is used to understand symptom severity. In accordance with Federal HIPAA regulations, this data will not be linked to an individual's personal identity.

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This site is published by EndoGastric Solutions, Inc., which developed it as an information resource to help increase awareness of GERD-related disorders and the available treatment options. This site is not a substitute for medical advice from your physician. The contents of the site are for informational purposes only and are intended to be discussed with your physician. Never disregard any advice given to you by your physician or other qualified health care professional. Always seek the advice of a physician or other licensed health care professional regarding any questions you have about your medical conditions and treatments.