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Clinical Survey Questionnaire

This form is to be completed ONLY by patients who have an appointment for an initial evaluation. This
IS NOT a general survey and your data will only be reviewed during a face-to-face interview and physical examination. You will need to fill it out, print it and submit the information then bring the hard copy to the office for your initial evaluation. You may need to contact your doctor for the specific information.

Date
First Name
Last Name
Address
City
State
Zip
Home Phone
Work Phone
E-Mail
SS#
Birth Date mm/dd/yyyy
 
Have you been diagnosed with gastroesophageal reflux disease (GERD)?
Yes
No
What do you perceive to be your reflux symptoms?
Do you experience these reflux symptoms at least two times weekly or more?
Yes
No
Do you experience heartburn and/or regurgitation?
Yes
No
Have you had asthma, cronic cough, hoarseness, throat pain, unexplained (non-cardiac) chest pain or swallowing difficulty?
Yes
No
If so, which symptoms?
asthma
cronic cough
hoarseness
throat pain
chest pain
swallowing difficulty
Have you been prescribed medications for GERD?
Yes
No
If so, medication name?

Other:
Do you take over-the-counter medications?
Yes
No
If so, medication name?
Other:
Frequency?
daily
weekly
monthly
other
Have you completely responded to the prescribed medical treatments?
Yes
No
Have you had an upper endoscopy?
Yes
No
Observed esophagitis severity grade?
0
1
2
3
4
Have you been diagnosed with Barrett's Esophagus?
Yes
No
Is dysplasia present?
Yes
No
Dysplasia grade?
Low
High
Other:
Do you have a hiatal hernia?
Yes
No
Approximate size?
Have you had an ambulatory pH monitoring study?
Yes
No
If so, was this performed on/off medical therapy?
On
Off
Please provide all of the following information:
% of total time
pH < 4
% upright time
pH < 4
% supine time
pH < 4
Longest single acid exposure episode
Total number of episodes with
pH < 4
Have you had an esophageal motility (manometry) study?
Yes
No
If so, please provide all of
the following information:
Average resting pressure of the lower esophageal sphincter (LES)
Length of the LES
Duration and amplitude of the esophageal contractions
% of failed or non-propulsed contractions
% of incomplete relaxation of the LES
Have you had previous thoracic (chest) or stomach surgery?
Yes
No
What is your
height (inches)
weight (pounds)


Contact Dr. Starpoli
AA Starpoli, MD
55 Montgomery Street, Poughkeepsie, NY 12601
1-845-471-1354

OR

AA Starpoli, MD
29 Washington Square West
New York, NY 10011
1-212-673-2721


 
   

© 2003-2008 AA Starpoli, MD. All Rights Reserved.

55 Montgomery Street, Poughkeepsie, NY 12601
Ph. 1-845-471-1354

29 Washington Square West, New York, NY 10011
Ph. 1-212-673-2721

Email. info@starpoli.com

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* This site is for informational purposes only! You should always consult with your doctor.
More reading about reflux with a foreword by Dr. Anthony Starpoli