Don't ignore your pain or discomfort. Complete this brief self-assessment to determine if you might benefit from therapeutic intervention.
Criteria
|
Severity |
Score |
|
Never |
1 |
|
Mild symptoms; not easy to recognize |
2 |
|
Significant symptoms; can be endured |
3 |
|
Serious symptoms; affect daily life |
4 |
|
Very serious symptoms; significantly affects daily functions |
5 |
|
Frequency |
Score |
|
No symptoms in the past one year |
1 |
|
Less than once a month |
2 |
|
At least once a month |
3 |
|
At least once a week |
4 |
|
At least once a day |
5 |
Self-Assessment
|
|
Severity (1–5) |
Frequency (1–5) |
|
Within the past 12 months, have you experienced any of the following symptoms: heartburn, chest burn, chest pain, coughing, voice transformation, hoarseness, uncomfortable feelings radiating from the chest to the throat, constant earache or sinusitis? |
|
|
|
Within the past 12 months, have you ever had gastric acid reflux? |
|
|
|
Within the past 12 months, have you ever had gastric acid reflux coming up to your throat? |
|
|
|
In the past 12 months, how many times did you take antacids or other medicines for stomach ailments? |
|
|
If your total score (severity and frequency) is 12 or more, contact your doctor to schedule a consultation or call our free physician referral service at 1-800-851-9780.
