--- title: Endoscopic Antireflux Procedure Patient Survey description: Dr, Starpoli uses esophyx and TIF to treat heartburn, hiatal hernia, gastroesophageal reflux, GERD --- [![Header Logo](https://www.starpoli.com/hs-fs/hubfs/GVG_Deep%20Blue.png?width=194&height=96&name=GVG_Deep%20Blue.png "Header Logo")](https://www.starpoli.com?hsLang=en-us) - [Reflux / Heartburn](https://www.starpoli.com/reflux-gerd-heartburn) - [Acid Reflux / Heartburn](https://www.starpoli.com/heartburn) - [GERDX](https://www.starpoli.com/gerdx) - [The EsophyX TIF Procedure](https://www.starpoli.com/esophyx) - [Stretta](https://www.starpoli.com/stretta) - [GERD Treatment Options](https://www.starpoli.com/gerd-options) - [BARRX Ablation Procedure](https://www.starpoli.com/treating-barretts-esophagus-0) - [Treating Barrett's Esophagus](https://www.starpoli.com/treating-barretts-esophagus) - [Abdominal Pain](https://www.starpoli.com/helio) - [Gastritis / Helicobacter Pylori](https://www.starpoli.com/helio) - [Peptic Ulcer Disease](https://www.starpoli.com/peptic) - [IBS / Constipation](https://www.starpoli.com/irritable-bowel-syndrome-nyc) - [Irritable Bowel Syndrome](https://www.starpoli.com/irritable-bowel-syndrome-nyc) - [Constipation](https://www.starpoli.com/constip) - [Lactose Intolerance](https://www.starpoli.com/lactose) - [Bacterial Overgrowth (SIBO)](https://www.starpoli.com/bacterial) - [Fecal Incontinence and Solesta](https://www.starpoli.com/fecal-incontinence-and-solesta) - [Probiotic Supplements](https://www.starpoli.com/probiotics) - [Hemorrhoids](https://www.starpoli.com/hemorrhoids) - [Hemorrhoids / CRH Hemorrhoidal Banding](https://www.starpoli.com/hemorrhoids) - [Infrared Coagulation](https://www.starpoli.com/hemorrhoids) - [Colitis](https://www.starpoli.com/colitis) - [Colon Polyps & Cancer](https://www.starpoli.com/colon) - [Liver Disorders (e.g. Hepatitis)](https://www.starpoli.com/hepatis) - [Weight Loss](https://www.stopobesity.com) - [Overweight Facts](https://www.stopobesity.com) - [Intragastric Balloons for Weight Control](https://www.stopobesity.com) - [Endoscopic Sleeve Gastroplasty](https://www.stopobesity.com) - [Gastric Bypass Failure - Revision & Repair](https://www.stopobesity.com) - [Nutritional & Behavioral Weight Management](https://www.stopobesity.com) - [BMI Calculator](https://www.starpoli.com/obesity-0/bmi-calculator) - Procedures - [GERDX](https://www.starpoli.com/gerdx) - [The EsophyX TIF Procedure](https://www.starpoli.com/esophyx) - [Stretta](https://www.starpoli.com/stretta) - [Stomach Balloons for Obesity](https://www.starpoli.com/obesity-balloons) - [Endoscopic Suturing for Obesity](https://www.starpoli.com/esg) - [CRH Hemorrhoidal Banding](https://www.starpoli.com/roids-0) - [Colonoscopy](https://www.starpoli.com/procedures/colonoscopy) - [Upper Endoscopy](https://www.starpoli.com/procedures/upper-endoscopy) - [BARRX Ablation Procedure](https://www.starpoli.com/treating-barretts-esophagus-0-0) - [Radiation Change Therapy](https://www.starpoli.com/radiation) - [Infrared Coagulation](https://www.starpoli.com/roids-0) - Aesthetics - [Medical Body Shaping of the Hudson Valley](https://www.hvbodyshaping.com) - Store and media - [Health Supplements & More](https://www.starpoli.com/supplements) - [Dr. Radio](https://www.starpoli.com/blog/dr-radio) - [In the News](https://www.starpoli.com/files-links) - [Video Forum](https://www.starpoli.com/forum) - [Dr. Starpoli's Blog](https://www.starpoli.com/blog) # Clinical Survey Questionnaire ### 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. [Faqs](https://www.starpoli.com/cs/c/?cta_guid=e719a302-ea8a-4fdb-ad84-47850a76ff86&signature=AAH58kGsrRgKAN0zr4UmTRP9NNWkF9L1Kw&pageId=67839153800&placement_guid=23b7209b-b2b1-4235-b4bf-5360dac0570c&click=bff54823-edee-4353-b576-80e8a483bf51&hsutk=9491909e9aaba689d64791264c2af579&canon=http%3A%2F%2Fwww-starpoli-com.sandbox.hs-sites.com%2Facid-reflux&portal_id=47367&redirect_url=APefjpFn_Ipt0XN47bdT02dCjskilMAij2owVci3uUz_x1Hwky1D16RQZDTV3NCGhZAYJrC-AIHFHAEvSn16D6RoyfTKuKGaL2Scq5ajNTSPJJh9laST0eXdp5TvPc56ta7Hy32Dw0zGjA0KwsY5B2xY2DMlkd3y6zL_JIJmZrvY7Cbd3x5JCYAsLhmqHloew_UQEJWvuydy8TCJ2qQQhrYFk4Ga9NRivTA-dqmToztLQCOr985swynfQ7VPLEM-X12vXY6CgyuX&__hstc=233546881.9491909e9aaba689d64791264c2af579.1646575594428.1646575594428.1646575594428.1&__hssc=233546881.1.1646575594430&hsLang=en-us) [Ask the Doctor](https://www.starpoli.com/cs/c/?cta_guid=7b24f21f-19e8-40cb-a264-bc6d55874c7c&signature=AAH58kF8ewQAXB13c3M7YcEuvBeVAICE1g&pageId=67839153800&placement_guid=fbf72da4-a7b3-4a45-aa84-3e34e6b13c93&click=97b7ef4c-baca-4c4a-9d91-10b06f9ca46b&hsutk=9491909e9aaba689d64791264c2af579&canon=http%3A%2F%2Fwww-starpoli-com.sandbox.hs-sites.com%2Facid-reflux&portal_id=47367&redirect_url=APefjpESUTC7EufKxE0fU_vjEsydbZ4zNf7vZafH0T94QRVQw8AY98tlGIo4FzfhbKi31x_H-yEHyfgb5jrmWCDRl8ReSR2w63piwbBHVVqQ-SisG_Cq2nPZI4w2zE--jYPPHgUamwCSc6APCVlBzOXRJZXuCuD9HQpQIPbOw-EFsHqau6gM6aHQabN9x0YWEiYylz_g6JG1ZDRVoD_ovV7YQ7xi7J_xPZ2xFfTejDtLUkMAFcK1SCp58XjSRGIJrOrbjz7B3jEv&__hstc=233546881.9491909e9aaba689d64791264c2af579.1646575594428.1646575594428.1646575594428.1&__hssc=233546881.1.1646575594430&hsLang=en-us) [Patient Portal](https://1209.portal.athenahealth.com/?&__hssc=&__hstc&hsCtaTracking=42d519d5-7dc8-4894-93e5-675f6d134128%7Cec669b6d-1a66-47e8-ac5d-9d55d49c8dfa) [Schedule with us](https://www.starpoli.com/schedule-appt/?hsLang=en-us) [![Greenwich Village Gastroenterolog](https://www.starpoli.com/hs-fs/hubfs/New-website/footer_logo.png?width=141&height=70&name=footer_logo.png) ](https://www.starpoli.com?hsLang=en-us) ** 80 5th Ave. Suite 1605 New York, NY 10011 ** 55 Montgomery St. Poughkeepsie, NY 12601 **[ 212 673 2721](tel:12126732721) **[ 845 471 1354 ](tel:18454711354) ** info@starpoli.com - [*facebook*](https://www.facebook.com/Dr.Anthony.Starpoli/) - [*instagram*](https://www.instagram.com/starpoligi/) - [*twitter*](https://twitter.com/StarpoliMD) - [*linkedin*](https://www.linkedin.com/company/greenwich-village-gastroenterology) - [Home](https://www.starpoli.com/?hsLang=en-us) - [Reflux / Heartburn](https://www.starpoli.com/reflux-gerd-heartburn?hsLang=en-us) - [Abdominal pain](https://www.starpoli.com/helio?hsLang=en-us) - [Hemorrhoids](https://www.starpoli.com/roids?hsLang=en-us) - [Weight Loss](https://www.starpoli.com/american-obesity-center-home?hsLang=en-us) - [Procedures](https://www.starpoli.com/esophyx?hsLang=en-us) - [Facial Tox](https://www.starpoli.com/facial-tox?hsLang=en-us) - [Dr. Starpoli's Blog](https://www.starpoli.com/blog?hsLang=en-us) - [IBS](https://www.starpoli.com/bowels?hsLang=en-us) © 2025 AA Starpoli, MD |[Office Policies ](https://www.starpoli.com/office-policies?hsLang=en-us) |[Privacy Policies ](https://www.starpoli.com/privacy-policy?hsLang=en-us)