REFLUX - Symptom Index & Quality of Life Assessment

REFLUX - Symptom Index & Quality of Life                 Assessment

Folks may like to copy/print this form to use in discussions with their health advisers.

[ At some point I will attempt a redesign to include a metric for frequency of incidence ---- all

suggestions gratefully received ]

07/04/15 ..Unfortunately it is not possible to post a good quality re-printable image on this site.

If anyone would like to reproduce this form please send me a private message quoting their email and I will send them a PDF.

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2 Replies

  • Thank you. I am sure that something like this would be of great help to those who are considering going to their GP with persistent heartburn, and that it would help the GP on the issue of referral for endoscopy for proper diagnosis. It does also include some symptoms that are reflux-related but not the cause of feeling heartburn, which can also be important.

  • Hi,

    Might be worth quoting the source to show that this is a validated instrument if used in discussions with health care professionals. Also adding the score that is considered to be the threshold of clinical significance would be helpful to those HCPs who would be unfamiliar with this (and also patients). I'v seen a total score of 13 being quoted as clinically significant in similar instruments (but I don't know about the the QOL part).

    All the best,


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