Name
*
First Name
Last Name
Date Of Birth
*
MM
DD
YYYY
Gender
*
Male
Female
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
These questions help us assess your symptoms and their severity to determine if treatment is appropriate.
*
What symptoms are you experiencing?
Text Describe your symptoms in your own words
*
How long have these symptoms been present?
*
Less than 1 week
1–2 weeks
Over 1 month
On and off for several months
Are symptoms worse after eating or when lying down?
*
Yes
No
Are you taking anything currently to relieve the symptoms (e.g., Gaviscon, omeprazole)?
*
Yes
No
If yes, please list what you’re taking and how often
Have you unintentionally lost weight?
*
Yes
No
Have you vomited blood or noticed black/tarry stools?
*
Yes
No
Have you experienced persistent vomiting or nausea?
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Yes
No
Are you over the age of 55 and experiencing new symptoms of indigestion?
*
Yes
No
Do you have a family history of stomach or oesophageal cancer?
*
Yes
No
Do you regularly consume spicy, fatty, or acidic foods?
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Yes
No
Do you consume more than 2 cups of tea, coffee, or fizzy drinks daily?
*
Yes
No
Do you drink alcohol?
*
Yes
No
Do you smoke?
*
Yes
No
Do you experience a lot of stress or anxiety?
*
Yes
No
Do you eat late at night or lie down soon after eating?
*
Yes
No
Have you ever been diagnosed with reflux, gastritis, ulcers, or H. pylori infection?
*
Yes
No
Do you currently take NSAIDs (e.g., ibuprofen, naproxen) or aspirin?
*
Yes
No
Do you take blood thinners (e.g., warfarin, apixaban)?
*
Yes
No
Do you take any regular medication?
*
Yes
No
Please list all your current medications (including over-the-counter)
Do you have any medication allergies?
*
Yes
No
If yes, please specify
Are you currently under care from a GP or specialist for digestive symptoms?
*
Yes
No
Would you like a summary of this consultation sent to your GP?
*
Yes
No
Anything else you’d like to add?
Consent & Declaration
