Heartburn and Reflux Assessment | Saint Luke's Health System

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

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Name

Age

Best way to reach you?

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

Is your heartburn or reflux worse after eating?

Yes

Does heartburn wake you up at night?

Yes

Have you had a hard time swallowing in the past month?

Yes

In the past month, have you felt a lump in your throat or as if food is stuck in your throat?

Yes

Do you have a cough unrelated to illness or allergies?

Yes

Is your throat sore or are you hoarse in the morning?

Yes

Is there anything else you’d like us to know?