Heartburn Questionnaire 940 E. El Camino Real Sunnyvale, CA 94087 harminder@homeopathicvibes.com www.homeopathicvibes.com Office Phone (408)737-7100 Office Fax (408)737-7102 Name *FirstLastEmail *PhoneHow often does your heartburn occur? OccasionallyWeekly3-4 times a week1-2 times a weekEvery day When does your heartburn occur? During the nightAfter eating When bending overWhen stressedAt random times Do you experience any of these symptoms? Frequent belching Frequent hiccuppingRegurgitating food into your mouthRegurgitating liquids into your mouthA sour or bitter taste in your mouth During your meal have you noticed these problems? Difficulty swallowing food Difficulty swallowing liquids Food getting caught in the upper chest area Food getting caught in the lower chest area Pain on swallowing Have any of these caused you concern? Feeling full after eating small amounts of foodRecent unexplained weight lossStomach or abdominal pain after eating Vomiting blood or black substancesUnable to swallow food and/ or liquids Have you recently had any of these? BloatingIndigestion or upset stomach NauseaVomitingVomiting without nausea How long do you go between bowel movements?A few hoursA day 4-6 daysA week or more Do you have any other symptoms? Chest pain when not swallowing Chest pain on exertionPersistent, dry coughHoarse voice or change in voice WheezingWhat tests and treatment have you done in the past? Esophagus scopedEsophageal surgeryStomach surgery Over-the-counter medication for your heartburnPrescription medications for your heartburn Do you have any abdominal pain on your lower left side? YesNoDo you have any abdominal tenderness? YesNoOccasionallyDo you have any blood in stool or vomits? YesNoOccasionallyDo you have any blood in stool or vomits? YesNoOccasionallyHave you ever consulted any Homeopath recently? YesNoLong Time agoIf yes, please give name Dr.How long treatment was taken? Less than month. Three to six months Longer than 6 months.What medicine do you take for your stomach? How much and when do you take it? How long have you been on the medicine? Have you had your esophagus scoped before?__________ When? Have you had any surgery done on your stomach?What kind of surgery? If any When did you have surgery? WebsiteSubmit