Infant Acid Reflux Questionnaire

This FREE Infant Acid Reflux Questionnaire is replied to by a medical support team member and is packed full of valuable information specific to your baby's GERD symptoms with treatment options to help your child.

Please note that all fields followed by an asterisk must be filled in.

First Name*

Last Name*

E-Mail Address*

Country*

Home Phone*

Your baby's name*

15 Minute Call*

	Yes I plan on scheduling my call and yes everyone involved in care will be on the call
	No I will not schedule my call and I no longer need to continue with this questionnaire

Your baby's age (actual, not adjusted if pre-term)*

Your baby's weight (IN POUNDS)*

Was your baby pre-term?*

	Yes
	No

Is This Your 1st Child With Reflux?*

	Yes
	No

How Long Have You Suspect Reflux*

	Less than a month
	1-3 months
	3-6 months
	Over 6 months

Check All Moderate Symptoms Lasting 4 Weeks or Longer

	Rubbing or Hitting Nose or Face
	Recurring or Abundant Hiccups
	Lack of Interest in Eating
	Crying During or Directly After Eating
	Crying When Laying Flat
	Difficulty Sleeping Unless Inclined
	Excessive Gas
	Excessive Nursing or Comfort Feeding
	Consistent Fussiness, Irritability, Restlessness
	Regular Sneezing w/o a Cold
	Spitting Up - Mouth or Nose
	Constant or Recurring Rash (Face or Neck)
	Rash On Face, Neck, Chest
	Wet Burping
	Abundant Salivation
	Acidic Spit Up (Sour or Vomit Odor)
	Biting Hands

Check All Moderate to Severe Symptoms Lasting 4 Weeks or Longer

	Gagging and Choking
	Gulping / Swallowing Hard or with Difficulty
	Snoring - Moderate
	Congestion or Loud Breathing
	Wheezing or Noisy Breathing
	Recurring Nasal Infections
	Recurring Ear Infections
	Laryngomalacia
	Shaking Head (Up/Down - Side/Side)
	Extreme Gas Causing Discomfort
	Twisting of Body (Especially After Feeding)
	Back Arching
	Inability to Sleep
	Constant Crying
	Diarrhea
	Constipation
	Clawing During Feeding
	Projectile vomiting
	Not Growing (Low in Age Percentile)
	Food Intolerances

Check All Severe Symptoms Lasting 2-4 Weeks or Longer

	Asthma, Respiratory Infections and Diseases
	Recurring Severe Respiratory Infections & Diseases (Nose, Throat)
	BRUE - Brief Resolved Unexplained Event (Baby Turning Blue or Purple)
	Snoring - Severe (Sleep Apnea)
	Breath Interruptions
	Lung Infections
	Ear Infections Leading to Hearing Lose
	Failure to Thrive (Caused by Pain Associated with Eating)
	Eating Aversions
	Dehydration
	Pneumonia
	Sinusitus
	Swollen Throat
	Seizure-like Symptoms (Sandifers Syndrome)
	MSPI & FPIES

List any special diets that you or your baby are on?

Any Additional Symptoms You'd Like To Explain*

I have tried the following treatments (currently or in the past)

	Nothing
	Gas Drops or Gripe Water
	Antacids
	Thickeners
	Formula Changes
	Elimination Diets (me and/or baby)
	Tonque / Lip Tie Revisions
	Elevation Wedges
	Erythromycin
	Domperidone / Reglan / Omidon / Metoclopramide
	Seziure Medications
	H2 Blockers
	Proton Pump Inhibitors
	Chiropractic
	Nissen Fondoplication

How Long On Each Medication?*

Are there any drug allergies? (List any or reply no)*

Are there any other illnesses or conditions we should know about?*

Additional Comments

How did you discover this questionnaire?*

On a scale of 1-10 how commited are you to getting your baby of pain? (1 = Least 10 = Most)*

	One
	Two
	Three
	Four
	Five
	Six
	Seven
	Eight
	Nine
	Ten

I am at least 18 years old*

Yes

I agree to the COPPA Disclaimer*

Yes

I agree to receiving follow up emails from the practice that can help my baby.*

Yes

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