Upset Stomach

Do you get heartburn?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Does your stomach get bloated?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you rub your chest with your hand in response to the pain you feel?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you have an unusual (e.g. burning) sensation in your throat?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Does a bitter liquid (acid) ever come up your throat?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you get heartburn if you bend over?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Does your stomach feel heavy after meals?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you ever feel sick after meals?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you get heartburn after meals?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you feel full while eating meals?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Does food feel like it's getting stuck when you swallow?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Do you burp?

  • Never
  • Occasionally
  • Sometimes
  • Often
  • Always

Is there anything else related to treatment that you'd like to ask or discuss with your medical provider?

Do you have a preferred treatment?

Would you like to share anything else with your provider through an upload?

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