Download Patient Forms/Patient Information Documents
Texas Reflux Patient Forms
Getting Ready for Your Visit
In order for us to provide the best care for you, it is very important that you bring the following items to your visit:
- Photo ID
- A list of your current medications
- Any and all photos from endoscopy
- Insurance information and card
- Information about what treatments and medications have been tried in the past
- Medical records from prior visits that you think may be helpful
- New Patients: download a patient registration below
GERD Questionairre
In order for us to provide the best care for you, please print this questionnaire before coming in for your appointment.
Scale:
0 = No Symptoms
1 = Symptoms noticeable, but not bothersome
2 = Symptoms noticeable and bothersome, but not every day
3 = Symptoms bothersome every day
4 = Symptoms affect daily activities
5 = Symptoms are incapacitating, unable to do daily activities
1. How bad is your heartburn?
0 1 2 3 4 5
2. Heartburn when lying down?
0 1 2 3 4 5
3. Heartburn when standing up?
0 1 2 3 4 5
4. Heartburn after meals?
0 1 2 3 4 5
5. Does heartburn change your diet?
0 1 2 3 4 5
6. Does heartburn wake you from sleep?
0 1 2 3 4 5
7. Do you have difficulty swallowing?
0 1 2 3 4 5
8. Do you have pain with swallowing?
0 1 2 3 4 5
9. Do you have bloating or gassy feelings?
0 1 2 3 4 5
10. If you take medications, does this affect your daily life?
0 1 2 3 4 5
11. How satisfied are you with your present condition?
Satisfied Neutral Dissatisfied
12. Are you currently taking any medications for heartburn or GERD? Yes No
Please select any of the medications you have taken in the past or are currently taking:
Nexium Zegerid
Prilosec Kapidex
Prevacid Dexilant
Aciphex Vimovo
Protonix
Your Zip Code:
Getting Ready for Your Visit
In order for us to provide the best care for you, it is very important that you bring the following items to your visit:
- Photo ID
- A list of your current medications
- Any and all photos from endoscopy
- Insurance information and card
- Information about what treatments and medications have been tried in the past
- Medical records from prior visits that you think may be helpful
- New Patients: download a patient registration below
GERD Questionairre
In order for us to provide the best care for you, please print this questionnaire before coming in for your appointment.
Scale:
0 = No Symptoms
1 = Symptoms noticeable, but not bothersome
2 = Symptoms noticeable and bothersome, but not every day
3 = Symptoms bothersome every day
4 = Symptoms affect daily activities
5 = Symptoms are incapacitating, unable to do daily activities
1. How bad is your heartburn?
0 1 2 3 4 5
2. Heartburn when lying down?
0 1 2 3 4 5
3. Heartburn when standing up?
0 1 2 3 4 5
4. Heartburn after meals?
0 1 2 3 4 5
5. Does heartburn change your diet?
0 1 2 3 4 5
6. Does heartburn wake you from sleep?
0 1 2 3 4 5
7. Do you have difficulty swallowing?
0 1 2 3 4 5
8. Do you have pain with swallowing?
0 1 2 3 4 5
9. Do you have bloating or gassy feelings?
0 1 2 3 4 5
10. If you take medications, does this affect your daily life?
0 1 2 3 4 5
11. How satisfied are you with your present condition?
Satisfied Neutral Dissatisfied
12. Are you currently taking any medications for heartburn or GERD? Yes No
Please select any of the medications you have taken in the past or are currently taking:
Nexium Zegerid
Prilosec Kapidex
Prevacid Dexilant
Aciphex Vimovo
Protonix
Your Zip Code: