Heartburn Questionnaire - HomeopathicVibes

Call Us: (408)-737-7100
Our Address: 940 E El Camino Real, Sunnyvale, CA - 94087 | 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538

Find us on Social Media:

Home
About
Conditions
Testimonials
Questionnaire
Contact
Consultation

Home
About
Conditions
Testimonials
Questionnaire
Contact
Consultation

Home
Heartburn Questionnaire

Why Me?

I'm providing homeopathic services for over 20 years in entire California. My clinic is located in Sunnyvale, Fremont, and San Jose. I have treated more than 1000 patients suffering from various conditions. I also provide online consultation if you're not able to visit any of my clinics. I have more than 100 five stars reviews on Google, Yelp, and other reviews websites. If you would like to know more about me, then feel free to reach me out by phone.

Quick Links

About Homeopathy
About Me
Gallery
Testimonials
Questionnaire
Contact

Conditions We Treat

Skin Conditions
Neurological Conditions
Stomach Conditions
Pulmonary Conditions
Alcoholism
Autoimmune Disease
Women’s Conditions

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 *

First

Last

Email *

How often does your heartburn occur?

Occasionally
Weekly
3-4 times a week
1-2 times a week
Every day

When does your heartburn occur?

During the night
After eating
When bending over
When stressed
At random times

Do you experience any of these symptoms?

Frequent belching
Frequent hiccupping
Regurgitating food into your mouth
Regurgitating liquids into your mouth
A 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 food
Recent unexplained weight loss
Stomach or abdominal pain after eating
Vomiting blood or black substances
Unable to swallow food and/ or liquids

Have you recently had any of these?

Bloating
Indigestion or upset stomach
Nausea
Vomiting
Vomiting without nausea

How long do you go between bowel movements?

A few hours
A day
4-6 days
A week or more

Do you have any other symptoms?

Chest pain when not swallowing
Chest pain on exertion
Persistent, dry cough
Hoarse voice or change in voice
Wheezing

What tests and treatment have you done in the past?

Esophagus scoped
Esophageal surgery
Stomach surgery
Over-the-counter medication for your heartburn
Prescription medications for your heartburn

Do you have any abdominal pain on your lower left side?

Yes
No

Do you have any abdominal tenderness?

Yes
No
Occasionally

Do you have any blood in stool or vomits?

Yes
No
Occasionally

Do you have any blood in stool or vomits?

Yes
No
Occasionally

Have you ever consulted any Homeopath recently?

Yes
No
Long Time ago

If 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?

Name

About Me

I have passion for homeopathy. I am blessed to be born in family of Homeopaths. My grand father Dr. Hazara Singh Gill was great homeopath of his times. He did his M.B.H (Bachelor of Medicine in Homeopathy) from Punjab Homeopathic Medical College Lahore in 1925.

Sunnyvale Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 940 E El Camino Real, Sunnyvale, CA 94087, United States
harminder@homeopathicvibes.com

Fremont Location

Phone: 408-737-7100
Fax: 408-737-7102
Address: 39039 Paseo Padere Parkway,Suite #209,Fremont, CA 94538, USA.
harminder@homeopathicvibes.com

Our Schedule

Weekdays: 10:00 am - 6.00 pm
Weekend: By Appointment only

Testimonials
Book Consultation
Questionnaire
Electronic Permission Form
Privacy Policy

© Copyright 2020 HomeopathicVibes | All rights reserved. Developed & Marketing By Qik IT Solution

Search for: