Reflux Symptom Index

The Reflux Symptom Index (Belafsky PC,)
Within the past month, how did the following affect you?

Hoarseness or a problem with your voice

Clearing Your Throat

Excess throat mucus or postnasal drip

Coughing after you ate or after lying down

Breathing difficulties or choking episodes

Troublesome or annoying cough

Sensation of something sticking in your throat or a lump in your throat

Heartburn, chest pain, indigestion, or stomach acid coming up

0 = No problem     5 = Severe

0        1        2        3        4        5

0        1        2        3        4        5

0        1        2        3        4        5

0        1        2        3        4        5

0        1        2        3        4        5

0        1        2        3        4        5

0        1        2        3        4        5

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  __________________