Reflux Symptom Index Name First Name Last Name Within the last MONTH how did the following problems affect you? 0 = no problem 5 = severe problem 1. Hoarseness or a problem with your voice 2. Clearing your throat 3. Excess throat mucous 4. Difficulty swallowing food, liquids or pills 5. Coughing after eating or after lying down 6. Breathing difficulties or choking episodes 7. Troublesome or annoying cough 8. Sensations of something sticking in your throat or a lump in your throat 9. Heartburn, chest, pain, indigestion, or stomach acid coming up Thank you!
