Infant Acid Reflux Questionnaire Part 2

This is the Infant Acid Reflux Questionnaire part 2.

It is a terrific tool in helping track your babies progress whether you are using TummyCare Max® or not. We are always available for questions so if you'd like someone to contact you please check the "yes" box at the end of the questionnaire for someone to contact you via email.

Thank you!

Infant Acid Reflux Questionnaire #2

Please note that all fields followed by an asterisk must be filled in.
Under 3 Months
3 Months to 6 Months
6 Months to 9 Months
9 Months to 12 Months
1 Year to 2 Years
2 Years or Older
Yes
No
Zantac
Ranitidine
Nexium Rx Packet 10mg
Nexium OTC Capsules 10mg
Nexium OTC Capsules 20mg
Nexium Rx Tablets 20mg
Nexium OTC Tablets 20mg
Nexium Control Tablets 20mg
Omeprazole OTC Capsules 10mg
Omeprazole OTC Capsules 20mg
Omeprazole OTC Tablets 20mg
Omeprazole Magnesium OTC Capsules 10 mg
Omeprazole Magnesium OTC Capsules 20mg
Prevacid OTC Capsules 15mg
Prevacid OTC Capsules 30mg
Prilosec OTC Tablets 20mg
Zegerid Rx Capsules 20mg
Irritable during eating
Refusal to eat
Only eats small amounts per feeding
Gags when eating
Arches back during feeding
Has difficulty swallowing
None of the above
Poor sleeping habits
Suffers from Apnea or Snoring
Has spells of not breathing
None of the above
Coughing without signs of a cold
Crying suddenly
Crying constantly
Not growing
Losing weight
Wheezing sound during breathing
Repetitive ear infections
Repetitive lung infections
Repetitive Sinusitis
None of the above
None
1-3 Times
4-6 Times
More than 6 times
None
Less than 1 tablespoon
1 tablespoon to 2 fluid ounces
2 fluid ounces to half of what you fed your child
Half of what you fed your child or more
Yes
No
Yes
No
Not at all
Less than 10 minutes
10 minutes to 1 hour
More than 1 hour but less than 3 hours
3 hours or more
Constant and uncontrollable crying
None
1 to 3 times
4 to 6 times
More than 6 times
None
1 to 3 times
4 to 6 times
More than 6 times
None
1 to 3 times
4 to 6 times
More than 6 times
Yes
No
Yes
No
None of the time
About a quarter of the time
About half of the time
All or almost all of the time
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No

Please enter the word that you see below.

  

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