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Gastroesophageal Reflux Disease (GERD) Questionnaire

The Gastroesophageal Reflux Disease (GERD) and Hiatal Hernia Surgery require an individualized approach, investigation and treatment. To achieve this, we need to know as much information as possible about your general medical history and your health problems.

Please, complete this questionnaire form as accurately as possible.

EN – Ερωτηματολόγιο Γαστροοισοφαγικής Παλινδρόμησης










PHONE No:






EMERGENCY CONTACT INFORMATION:



WEIGHT HISTORY



CURRENT ILLNESS


Diet and Lifestyle Changes


ASSESSMENT OF QUALITY OF LIFE WITH GASTROESOPHAGEAL REFLUX DISEASE (GERD)


Score:
0 = No symptoms
1 = There are symptoms but are not annoying
2 = There are annoying symptoms but not on a daily basis
3 = There are annoying symptoms on a daily basis
4 = There are symptoms that affect daily activities
5 = There are symptoms that interfere with daily activities
Choose the one that best describes your quality of life in the last 2 weeks.
1. How annoying are heartburns?
2. How annoying are heartburns when you’re lying down?
3. How annoying are heartburns when you’re standing up?
4. How annoying are heartburns after eating?
5. Does heartburn force you to limit or avoid some foods?
6. Do you wake up at night with intense heartburn?
7. Do you have difficulty swallowing?
8. Do you have pain when swallowing?
9. If you take medications, do they affect your daily life?
10. How annoying is regurgitation (a sensation of food or liquid coming up into the throat or mouth)?
11. How annoying is regurgitation when you’re lying down?
12. How annoying is regurgitation when you’re standing up?
13. How annoying is regurgitation after eating?
14. Does regurgitation force you to limit or avoid some foods?
15. Do you wake up at night with regurgitation?
16. How do you feel with the current situation?

PAST MEDICAL HISTORY (PMH)
PEDIATRIC MEDICAL HISTORY




ADULT PATIENT MEDICAL HISTORY
Please, note below any diseases that you suffer from, are being treated for or you have been hospitalized in the past.
Other diseases (please, describe here in detail)

FOR WOMEN





FOR MEN



PAST SURGICAL HISTORY

Describe the type of surgery, date, hospital and outcome – complications




MEDICATIONS

Please, note all medications that you are currently using and their dosages. Do not neglect to mention the medications that are not taken daily but only when symptoms are present.









ALLERGIES





FAMILY HISTORY
Is there a family history with significant medical conditions such as diabetes, heart disease, obesity, cancer, etc.?

Father:



Mother:


Brothers and Sisters:


SOCIAL HISTORY











GASTROINTESTINAL






CARDIOVASCULAR



RESPIRATORY





URINARY




NEUROLOGIC




MENTAL HEALTH





OTHER HISTORY DETAILS & COMMENS

INFORMED CONSENT INFORMATION