GERD Evaluation Form

TNE - Transnasal Esophagoscopy

LINX - Antireflux System

Hiatal Hernia Repair

Gastric Sleeve

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The Surgical Practice of Robert Sewell, M.D., F.A.C.S.

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Call 817-749-0206
for your appointment

Seeing patients in the offices of

Wise County Medical & Surgical Associates

1001 W. Eagle Dr.

Decatur, Texas 76234

GERD/Reflux Evaluation Form

In a few words, describe how your symptoms are impacting your life.

How would you describe your symptoms over the last few months?

Improving somewhat

About the same

Progressively getting worse

If Yes, what is you GI doctor's name?

Have you ever been told you have one or more of the following conditions?

Hiatal Hernia

Esophageal Stricture

Barrett's Esophagus

Esophageal Achalasia

Poorly Functioning Esophagus

None of the Above

Have you had any other prior tests for reflux? (check all that apply)

I have had an upper GI X-ray (Swallowing barium liquid under x-ray)

I have had an Esophageal Motility to check the function of my esophagus

I have had 24 or 48 hour pH testing

I have not had any other tests

Are you currently taking over the counter medications for heartburn or reflux?

Yes, I use antacids (Tums, Rolaids, etc.)

Yes, I use over the counter acid suppressing medication (Zantac, Pepcid AC, Prilosec OTC, or similar)

Are you currently under the care of a physician for reflux or other GI conditions?

Yes

Have you ever had surgery on your esophagus or stomach? (Check all that apply)

I have not had any surgery for reflux

I've had a previous Hiatal Hernia repair

I've had a Fundoplication (Stomach Wrapped around Esophagus)

I've had a Lap Band for weight loss

I've had a Gastric Sleeve for weight loss

I've had a Gastric Bypass for weight loss

I've had a Myotomy for Achalasia

Please list your heartburn/reflux medications, the dosages, and the frequency.

Are you currently taking prescription medication for heartburn or reflux? (Check all that apply)

I'm not on any prescription medicine

Yes, I take prescription medication, but only when I need them

Yes, I take prescription medication daily

Yes. I take prescription medication twice a day

How well are your heartburn/reflux medication working? (Check all that apply)

My current medication works pretty well

I still have breakthrough symptoms

The medicine doesn't seem to help all that much

I quit taking my medication because they didn't work

I quit taking my medication because of the side effects.lying down

If Yes, how often do you take over the counter remedies?

Once a week or less

two or three times a week

Nearly every day

once a day

more than once a day

When was the last time you had an Upper GI Endoscopy? (a procedure to look down your esophagus and into your stomach)

Never

within the last year

within the last two years

more than two years ago

Please take a moment to fill out this questionnaire. It will help us determine if we can help you. Your personal information is absolutely safe. We never share any of our patient's personal information with anyone, at anytime, for any reason.