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

First Name*

Last Name*

E-Mail Address*

Country*

CountryUnited StatesCanada----------------AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribadiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoFederated States of MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMontenegroMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamUS Virgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (former)ZaireZambiaZimbabwe

Home Phone*

Your baby's name*

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

Your baby's weight (IN POUNDS)*

Was your baby pre-term?*

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 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) MSPI & FPIES

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

Any Additional Symptoms You'd Like To Explain*

List of Any Medications Being Given (Include Dose/Times Per Day)*

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 arrive at this questionnaire?*

I agree to the COPPA Disclaimer*

Yes

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