Reflux Symptom Index
The Reflux Symptom Index (Belafsky PC,)
Within the past month, how did the following affect you?
0 = No problem
5 = Severe
5 = Severe
Hoarseness or a problem with your voice
0
1
2
3
4
5
Clearing Your Throat
0
1
2
3
4
5
Excess throat mucus or postnasal drip
0
1
2
3
4
5
Difficulty swallowing food, liquid, or pills
0
1
2
3
4
5
Coughing after you ate or after lying down
0
1
2
3
4
5
Breathing difficulties or choking episodes
0
1
2
3
4
5
Troublesome or annoying cough
0
1
2
3
4
5
Sensation of something sticking in your throat or a lump in your throat
0
1
2
3
4
5
Heartburn, chest pain, indigestion, or stomach acid coming up
0
1
2
3
4
5
Total
GERD/LPR Checklist for Diet/Lifestyle Management
Answer YES or NO to each of the 10 questions. Answer questions based on the last month.
I eat spicy, acidic, tomato- based, fatty foods, chocolate, peppermint, citrus fruits, fruit juices.
I am overweight and have extra weight around my waist.
I only eat 2-3 large meals a day.
I exercise right after I eat.
I wear tight, restrictive clothes around my waist.
I drink coffee, tea, alcohol, and colas.
I smoke.
I lie down right after I eat.
I lie flat on my bed and do not elevate the head of my bed EXCEPT for pillows
I do NOT take the reflux medication as prescribed by my physician.
Compliance Rating:
*Score = 10 minus # of YES responses
*Score = 10 minus # of YES responses
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