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Call 714-545-5200

8101 Newman Ave. Suite D Huntington Beach, CA 92647

631 Brookhurst St., Suite 214 Anaheim, CA 98804

26781 Portola Parkway, Suite 4E Foothill Ranch, CA 92610

HOME
OUR OFFICES
OUR TEAM
WHAT IS GERD?
TESTIMONIALS
PATIENT QUESTIONNAIRE
CONTACT
FAQS

Patient Questionnaire

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Contact Us

Name

Phone

Street Address

City

Primary Care Physician

1. How did you hear about OC Reflux?

Newspaper

Flyer

Website

Other

2. How long have you suffered with reflux?

0-5 years

6-10 years

11-15 years

Over 15 years

3. What symptoms are you experiencing (please check all that apply)

hoarseness

regurgitation

difficulty sleeping

persistent cough

dental erosions

can’t eat desired foods

asthma

other

4. What is your current age?

< 40

40-50

51-60

> 60

5. How do you currently treat your reflux?

PPIs,

H2blockers

Other

6. How often do you take medication for your reflux?

2 pills daily

1 pill daily

1 pill weekly

1 pill monthly

7. Who do you currently see regarding your reflux?

General Practitioner

Internal Medicine

ENT

OBGYN

Gastroenterologist

Pulmonologist

8. Have you ever been consulted about the current laparoscopic surgical procedure for reflux?

Yes

Option 2

If yes, why this medical option has not been used to treat your reflux?

9. How satisfied are you with your current treatment? Extremely satisfied?

Not at all satisfied

10. Do you have additional questions?

Yes

11. Would you like us to contact you?

Yes

Thank you for contacting us.
We will get back to you as soon as possible.

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OC Reflux is Orange County's leading center for treatment of acid reflux, also known as gastroesophageal reflux disease.

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8101 Newman Ave. Suite D Huntington Beach, CA 92647 714-545-5200 714-831-0007

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