Reflux Symptom Self Test
Within the last month, how did the following problems affect you?
0 = no problem 5 = severe problem
| 1. Hoarseness or a problem with your voice. |
0 |
1 |
2 |
3 |
4 |
5 |
| 2. Clearing your throat |
0 |
1 |
2 |
3 |
4 |
5 |
| 3. Excess throat mucous or post nasal drip. |
0 |
1 |
2 |
3 |
4 |
5 |
| 4. Difficulty swallowing food, liquids, or pills. |
0 |
1 |
2 |
3 |
4 |
5 |
| 5. Coughing after you ate or after lying down. |
0 |
1 |
2 |
3 |
4 |
5 |
| 6. Breathing difficulties or choking episodes. |
0 |
1 |
2 |
3 |
4 |
5 |
| 7. Troublesome or annoying cough. |
0 |
1 |
2 |
3 |
4 |
5 |
| 8. Sensations of something sticking/lump in throat. |
0 |
1 |
2 |
3 |
4 |
5 |
| 9. Heartburn, chest pain, indigestion, or stomach acid coming up. |
0 |
1 |
2 |
3 |
4 |
5 |
Reflux symptom self test score greater than or equal to 10 is significant. You may want to share your test score with your physician.
If you scored 10 or greater and would like to be contacted about the TIF procedure, fill out the form below.