Infant Acid Reflux Questionnaire

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We answer each Infant Acid Reflux Questionnaire individually and is specific to your child's symptoms.

It goes directly to one team member supporting our on staff Pediatrician that specializes in infant reflux and failure to thrive, Dr. Jennifer Prince.

Please note that all fields followed by an asterisk must be filled in.
Yes
No
Less than a month
1-3 months
3-6 months
Over 6 months
Rubbing or Hitting Nose or Face
Recurring or Abundant Hiccups
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
Lack of Interest in Eating
Food Intolerances
Extreme Gas Causing Discomfort
Gagging and Choking
Gulping / Swallowing Hard or with Difficulty
Snoring - Moderate
Congestion or Loud Breathing
Wheezing or Noisy Breathing
Chronic Coughing
Recurring Nasal Infections
Recurring Ear Infections
Shaking Head (Up/Down - Side/Side)
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)
Asthma, Respiratory Infections and Diseases
Blue Baby Syndrome (Apparent Life Threatening Event)
Purple Baby Syndrome (Apparent Life Threatening Event)
Life Threatening Apnea
Snoring - Severe (Sleep Apnea)
Breath Interruptions
Chronic Coughing
Gagging & Choking (Severe)
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)

Please enter the word that you see below.

  

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