Please answer the following questions by ticking the appropriate box in front of each question

How many times does this occur per week?

0 day

1 day

2-3 days

4-7 days

How often did you have a burning sensation behind your breastbone (heartburn)?

How often did your stomach contents (liquid or food) move upward to your throat or mouth (regurgitation)?

How often did you have pain in the center of the upper stomach?

How often did you have nausea?

How often did you have difficulty getting a good night's sleep due to your heartburn and/or regurgitation?

How often did you take additional medication for your heartburn and/or regurgitation, other than what the physician told you to take (such as Tums, Rolaids, and Maalox)?