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GERD Risk Assessment Questionnaire
1.
Do you currently smoke cigarettes, or not?
Yes, I do
Occasionally
No, I do not
2.
Are you more than 10% above your ideal bodyweight?
Yes
No
3.
Do you eat out often?
Yes
Occasionally
No
4.
Do you get frequent heartburn or chest pains (especially after eating)?
Yes
Occasionally
No
5.
Do you suffer from indigestion, burping, nausea after eating, or stomach bloating?
Yes
Occasionally
No
6.
Do you face difficulties in breathing or swallowing?
Yes
Sometimes
No
7.
Do you often feel hoarseness in your throat primarily in the morning?
Yes
Occasionally
No
8.
Do you suffer from a chronic cough?
Yes
Occasionally
No
9.
Are you prone to dental cavities or enamel erosions?
Yes
Occasionally
No
10.
Do you experience regurgitation or vomiting reflex often?
Yes
Occasionally
No
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