Acid Reflux Survey

Acid reflux

If you have persistent chest pain and are unsure if it is due to heartburn, seek emergency medical attention.

    Choose your Location

    What is your date of birth?

    Which symptoms do you experience? select all that apply to you

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    When do you experience acid reflux symptoms? Select all that apply to you

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    What triggers your Acid reflux symptoms? Select all that apply to you

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    How often have you had acid reflux symptoms?

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    Have you ever taken any over-the-counter (OTC) antacids or heartburn medicines for these symptoms?

    Are you allergic to any medicine?
    Please list your drug allergies and what happens when you use that drug.

    Do you find that antacids only provide temporary relief from your symptoms?

    Do you take other medication(s) or have any other medical conditions?

    Please include any antibiotics, name of birth control, as well as any over-the-counter and herbal dietary or potassium supplements.

    In order for us to provide you with the best care, please let us know what medications you take and what conditions you have.

    Do you have any of these conditions?.

    Anything else you would like us to know?

    Tell us about any concerns or questions you have for the medical team.

    How would you like to pay?

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    Billing and delivery details

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    Delivery Location
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    Personal Details

    First Name: Last Name:
    Date of Birth:
    Mobile Number: E-mail:

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