Heartburn and Reflux Assessment Main navigation Find a Provider Locations Conditions & Treatments Continuing Care Patient Resources Giving To learn about available treatment options for your heartburn and reflux symptoms, please complete this assessment. Our team will contact you to set up a consultation. Name Age Best way to reach you? Email Phone Email Phone Best time to reach you by phone I don’t want to fill out the form below and prefer someone contact me directly Do you have heartburn more than twice a week? Yes No Is your heartburn or reflux worse after eating? Yes No Does heartburn wake you up at night? Yes No Have you had a hard time swallowing in the past month? Yes No In the past month, have you felt a lump in your throat or as if food is stuck in your throat? Yes No Do you have a cough unrelated to illness or allergies? Yes No Is your throat sore or are you hoarse in the morning? Yes No Is there anything else you’d like us to know?