Acid Reflux at Home Test
Reflux Symptom Index
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 __________________