Never Almost never Unless twice a week Sometimes everyday Constantly click to choose an option
2. Tell us now with more detail about it. Measure yourself on the "Richter Scale" Acid Test How significant is your heartburn? What are the chances that is something more serious? A panel of experts from the American College of Gastroenterology developed a self-test to help gauge the severity of heartburn problems. This test is reproduced within the red frame.
Do you frequently experience one or more of the following symptoms:YesNo An uncomfortable feeling behind the breastbone that seems to be moving upward from the stomach? A burning sensation in the back of your throat? A bitter, acid taste in your mouth? Do you often experience the above problems after meals? Do you experience heartburn or acid indigestion two or more times per week? Do you find that antacids only provide temporary relief from your symptoms? Are you taking prescription medication to treat heartburn but you are still experiencing symptoms?
1 2 3 4 5 6 7 No one choose a number
If you said YES to two or more questions, you may have Gastroesophageal Reflux Disease (GERD). To know for sure, see your doctor or a gastrointestinal specialist. (Richter Scale reproduced with permission from Dr. Richter).
Please, continue with the survey
I don't smoke I am ex-smoker I smoke less than 10 cigarettes a day I smoke less than one pack a day I smoke less than two packs a day I smoke two packs a day I smoke more than 2 packs a day choose one
5. Do you drink alcohol?
Never I take less than one alcoholic drink a day I take some alcoholic drink a day I take more than one alcoholic drink a day I take more than twice a day, alcoholic drinks I take alcoholic drinks three times a day I take alcoholic drinks more than three times a day choose one option
6. Do you eat chocolate or mint?
No Once a week twice a week almost every day every day Chocolate Mint
No Less than once a week Some days a week Once every two days Every day Choose an option
8. Weight
Write your weight in kilograms (example: 67) -------------> If you only know the weight in pounds, use this other box-->
Write here your height in centimeters (example: 175) -------> If you prefer feet, please use this other box (example:5"6)--->
Yes No
11. Are you taking some medicine to treat your heartburn? (antacids are also medicines)
Yes No (if you answer no, click here and continue)
12. Please write what medicacion are you currently taking for your heartburn (enter one medicine in each blank, in case you are taking more than one medicine for your heartburn)
medicine 1 medicine 2 medicine 3 medicine 4
Doctor prescribes it to me Someone recommend it to me I saw it in an advertisment Another reason choose one option
14. How long have you been taking medicine 1?
Less than one month Less than 6 months Less than a year Between one and two years Less than 4 years More than 4 years choose one option
15. How do you feel about the results of medicine 1?
Great, I have no heartburn I am better, but sometimes with disconforts I am the same than before I am worst than before choose an option
If you are only taking one medicine, click the below link
Go to question 30
But if you are taking more than one medicine, continue here
31. Why are you taking medicine 2?
32. How long have you been taking medicine 2?
33. How do you feel about the results of medicine 2?
If you are only taking those two medicines, click the below link
But if you are taking more than those two medicines, continue here
34. Why are you taking medicine 3?
35. How long have you been taking medicine 3?
36. How do you feel about the results of medicine 3?
If you are only taking those three medicines, click the below link
But if you are taking more than those three medicines, continue here
37. Why are you taking medicine 4?
38. How long have you been taking medicine 4?
39. How do you feel about the results of medicine 4?
We would like to clarify that usually only one medicine is taken for heartburn. Sometimes two, and rarely more.
Thank you for your collaboration in this study, let's analize now the adverse events.
30. Do you think that the medicines you are taking are causing you some of these problems? (click all that applies)
I got no problems Nausea Vomits Diarrhea Constipation Flatulence Dizziness Fatigue Sleepy Blurred vision Itching Skin bead or blotch Belly pain Headache Indigestion Anxiety Agitation Confusion Hallucinations Ankle inflammation Other alterations
Hiatal Hernia Esophagitis Barrett's esophagus Esophageal ulcer Gastric ulcer Duodenal ulcer Gastritis Duodenitis Asthma
17. Have you ever been operated for hiatal hernia, esophagitis, Barrett's esophagus or GERD (Gastroesophageal Reflux Disease)?
No (if you say no, click here and continue) Yes (if you say yes, continue with question #18)
18. When was the operation?
Less than 3 months ago Less than 6 months ago Between 6 months and 1 year ago Between one and two years ago Between two and four years ago More than 4 years ago choose an option
19. How is the scar of the operation?
It is a big scar in the side of the thorax It is a big scar in the belly They are several little scar in the belly (no one bigger than 1 inch [3cm]) choose an option
20. Do you remember what surgical technique was done?
I do not know Nissen (also called complete wrap fundoplication 360º) Toupet (posterior or partial fundoplication 240 ó 270) Belsey (they operated me through the chest) Miotomy, they cut the sphincter They put me a plastic artificial sphincter choose one
21. Are you happy about the result of the operation?
Very happy, I am cured I am better than before, but not perfect I am the same than before the operation My symptoms are worst since the operation I am much worst than before the operation choose an option
22. Are you taking any medication since the operation was performed?
Yes No (Go to Question24)
23. Write the name of the medicines, please
It is terrific It is good It is standard It is not too bad I do not like it choose an option
25. Have you been able to see the pages and pictures displayed without problems?
26. You can write here any comments you would like to send us.
27. Sex
Female Male
28. Date of birth
Write the date in this format please: day-month-year
Example 28-09-1967
Country Province or State Initials (of your name and last name) E-mail
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