Assessing GERD

Don't ignore your pain or discomfort. Complete this brief self-assessment to determine if you might benefit from therapeutic intervention.


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


  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.