| GORD Self Evaluation Tool |
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By filling out this simple questionnaire and booking an appointment, both you and your GP will be better placed to
understand your current situation.
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| 1) |
Have you ever experienced a burning sensation rising up from your stomach, or lower chest, towards your neck? |
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| a) |
No |
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| b) |
Yes, occasionally (e.g. after a spicy meal or alcohol) |
|
| c) |
Yes, less than 3 times a week |
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| d) |
Yes, 3 or more times a week |
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| 2) |
Have you ever experienced regurgitation, which is an unpleasant movement
of material upwards from your stomach into your mouth? |
|
| a) |
No |
|
| b) |
Yes, occasionally (e.g. after a spicy meal or alcohol) |
|
| c) |
Yes, less than 3 times a week |
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| d) |
Yes, 3 or more times a week |
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| 3) |
Do you suffer from these symptoms at night-time? |
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| a) |
No |
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| b) |
Yes, occasionally (e.g. after a spicy meal or alcohol) |
|
| c) |
Yes, less than 3 times a week |
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| d) |
Yes, 3 or more times a week |
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| 4) |
Have you ever taken an over the counter or pharmacy medication for
these symptoms (e.g. Zantac, Mylanta, Quick-eze, Rennie etc.)? |
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| No |
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| Yes |
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| 5) |
Mark on the below scale how much these symptoms affect your
quality of life with 0 being no impact and 10 dramatically affecting your enjoyment of life. |
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| 6) |
If you changed to a stronger or prescription based medicine, how
quickly do you expect to get relief? |
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| a) |
Within 1 hour |
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| b) |
Within 1 day |
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| c) |
Within 1 week |
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| d) |
Within 1 month |
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