Gastroesophageal Reflux Disease (GERD) Assessment

Your Name*

Gender*

Date of Birth*

Telephone No.*

Height (m)*

Weight (kg)*

Please complete the below questionnaire

In the past 6 months, please select if you have any of the followings at least twice a month:

Experience pain or discomfort in the middle of your chest

Heartburn

Experience food or liquid from stomach towards mouth or acid regurgitation

None of the above

I would like to receive gastrointestinal-related information from CUHK Medical Center

I am interested in participating health check or research organized by CUHK Medical Centre

I agree to provide my above information to CUHK Medical Centre for the use in research

I agree to be contacted by centre staff for preliminary consultation