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First Name:
Last Name:
Email:
Phone:
What is your current rating?
N/A
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Please list down all CURRENT Disability/ies and rating/s for each. (Write N/A if you do not have any current disability rating. Eg PTSD 70%, Sleep Apnea 50%)
Please list any medication, prescription, and over-the-counter medicine that you take FOR ANY OF YOUR SERVICE CONNECTED DIABILITIES.
Have you ever been diagnosed with the condition you are being prescreened for? If yes, please explain in the box provided below.
Yes
No
Which of the following best describes your main complaint?
Burning sensation in your upper abdomen / stomach
Burning sensation in your chest and throat
Nausea or vomiting
Pain in the middle of your chest when you eat
Other
Which of the following best describes the timing of your complaint?
Any time. There is no relation to eating
Within the first 2 hours after eating
Always occurs at the same time of the day or night with no relation to eating
Other
You eat much more than you're accustomed to?
Worse
Better
Nothing happens
You eat fatty foods?
Worse
Better
Nothing happens
You eat spicy or highly seasoned foods?
Worse
Better
Nothing happens
What happens to your symptoms after you take antacids?
Nothing
Complete relief within the first 15 minutes
Complete relief after about 15 minutes
I don't take antacids
What happens to your symptoms when you bend over or lie down?
Nothing
They get worse
They get better
Which of the following best describes the effect that carrying heavy objects, straining or performing strenuous exercise has on your symptoms?
No effect
They get worse
They get better
If you regurgitate the contents of your stomach into your throat or mouth, what happens insofar as your main complaint is concerned?
Nothing
It gets worse
Regurgitation is what causes my main complaint
It gets better
I don't regurgitate
Over the past week, how many days have you experienced a burning sensation in your chest?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you been bothered by the contents of your stomach coming up into your throat or mouth?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you experienced pain in your upper abdomen / stomach?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you been nauseated or felt like vomiting?
Never
1 day
2-3 days
4-7 days
Over the past week, how many nights have you had difficulty sleeping because of burning pain in your chest or because the contents of your stomach have come up into your throat or mouth?
Never
1 day
2-3 days
4-7 days
Over the past week, how many days have you taken any type of medication or home remedy for burning pain in your chest or because the contents of your stomach have come up into your throat or mouth?
Never
1 day
2-3 days
4-7 days
