New Appointment Questionnaire

Infant Acid Reflux Solutions

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*

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

Please enter the word that you see below.

COPPA Disclaimer

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