Heartburn Form | Broward Health

Contact Information

First and Last Name

Phone Number

Email

Patient History

Do you have a GI doctor?

No

Yes

Have you had a recent endoscopy?

No

Yes

Have you been diagnosed with a hiatal hernia?

No

Yes

Have you had any of these prior surgeries?

Primary Symptoms

Check all that apply:

Difficulty swallowing/dysphagia

Heartburn

LPR/extra-esophageal symptoms (cough/hoarseness/voice changes)

Reflux/Regurgitation

Treatment Goals

Check all that apply:

Barrett’s Management

Improved Quality of Life

Reduce need for Medications

Repair Hiatal Hernia

Symptom Relief

Message

Please provide any additional details:

Events