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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.



Have you been diagnosed with gastroesophageal reflux disease (GERD)?


Do you experience these reflux symptoms at least two times weekly or more?


Do you experience heartburn and/or regurgitation?


Have you had asthma, cronic cough, hoarseness, throat pain, unexplained (non-cardiac) chest pain or swallowing difficulty?


If so, which symptoms?






Have you been prescribed medications for GERD?


Do you take over-the-counter medications?


Frequency?




Have you completely responded to the prescribed medical treatments?


Have you had an upper endoscopy?


Observed esophagitis severity grade?





Have you been diagnosed with Barrett's Esophagus?


Is dysplasia present?


Dysplasia grade?



Do you have a hiatal hernia?


Have you had an ambulatory pH monitoring study?


If so, was this performed on/off medical therapy?


Have you had an esophageal motility (manometry) study?


Contact Dr. Starpoli

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

OR

AA Starpoli, MD
80 5th Avenue - Suite 1605
New York, NY 10011
1-212-673-2721