Infant Acid Reflux Questionnaire

Get answers from a real doctor now
FREE!

This Infant reflux questionnaire will go to a doctor that specializes in infant acid reflux and they will get you answers for free. It was created by a group of medical professionals and they will help you find out if your baby is showing signs of infant acid reflux. 

You can also print out this PDF version so you can keep a reflux journal to show your doctor or for your own records. This is a great tool to keep track of symptoms and treatment results.

Either option, this questionnaire will give you the tools to find your child's best treatment options offered to you by a doctor that specializes in infant acid reflux.

Infant Acid Reflux Questionnaire

Please note that all fields followed by an asterisk must be filled in.
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
Suffers from colic
Unusually frequent hiccups
Wet Burps or liquid comes up during burping
Spitting up during feeding
Spitting up after feeding
Frequent vomiting
Acid odor to the vomit
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
Not gaining
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
Total Illimination Diet (TED)
Thickening Feeds
Special Formulas
Probiotics
Antacids
Cherry Supreme
H2 Blockers
Gripe Water
Proton Pump Inhibors
Surgery (Nissen Fundoplication)
Surgery (Tongue Tie Revision)
Chiropractic
Yes
No
Infant Acid Reflux Solutions Facebook Group
Reflux Rebels Facebook Group
Reflux Support Group Facebook
Baby Reflux- Support for parents
Acid Reflux Babies Support Group
Instagram
Pinterest
Facebook Ad
Google Search
Online Article Publication
Friend Referral
Other

Please enter the word that you see below.

  

The Infant reflux questionnaire was developed by a group of well respected physicians and researchers, then validated in the studies known as MarciKids. To find out more about the what MarciKids is and the principles behind the recommendations please read our PPI dosing page.

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