GORDcalc

Do you suffer from heartburn or indigestion?

  1. Have you ever experienced a burning sensation rising up from your stomach, or lower chest, towards your neck?

  2. Have you ever experienced unpleasant movement of material upwards from your stomach into your mouth?

If the answer to either of the above is yes, take some positive steps towards overpowering these symptoms.

GORD Self Evaluation Tool

By filling out this simple questionnaire and booking an appointment, both you and your GP will be better placed to
understand your current situation.

1) Have you ever experienced a burning sensation rising up from your stomach, or lower chest, towards your neck?  
a) No
b) Yes, occasionally (e.g. after a spicy meal or alcohol)
c) Yes, less than 3 times a week
d) Yes, 3 or more times a week
2) Have you ever experienced regurgitation, which is an unpleasant movement
of material upwards from your stomach into your mouth?
 
a) No
b) Yes, occasionally (e.g. after a spicy meal or alcohol)
c) Yes, less than 3 times a week
d) Yes, 3 or more times a week
3) Do you suffer from these symptoms at night-time?  
a) No
b) Yes, occasionally (e.g. after a spicy meal or alcohol)
c) Yes, less than 3 times a week
d) Yes, 3 or more times a week
4) Have you ever taken an over the counter or pharmacy medication for
these symptoms (e.g. Zantac, Mylanta, Quick-eze, Rennie etc.)?
 
No
Yes
5) Mark on the below scale how much these symptoms affect your
quality of life with 0 being no impact and 10 dramatically affecting your enjoyment of life.
 
0 1 2 3 4 5 6 7 8 9 10
6) If you changed to a stronger or prescription based medicine, how
quickly do you expect to get relief?
 
a) Within 1 hour
b) Within 1 day
c) Within 1 week
d) Within 1 month
 
 
 
 

This information will be collected for educational purposes, however it will remain anonymous.

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