Acid reflux surgery eligibility

Please complete the following questions then click send to submit your enquiry and see if you’re elibible for acid reflux surgery. We will contact you shortly to discuss your reflux symptoms and the surgical options available to you…

Your Name* Your Email* Your Tel no* Your Date of Birth

1. How long have you had symptoms of GORD* (to nearest whole year) years

2. Are you taking regular medication?*  Yes No

2a. If yes, what medications are you taking?*

3. What are your symptoms?* (tick all that apply)  Heartburn (reflux) Nausea Bloating/Belching Pain swallowing hot drinks Pain in chest/arms Lump in throat Cough (especially at night) Hoarseness Wheezing/asthma Repeated chest infection

4. How tall are you?* ft ins OR cms

5. What is your current weight?* st lbs OR kg

6. Have you had a gastroscopy?*  Yes No

7. Are you still having symptoms despite being on regular medication?*  Yes No

8. Have you had a 24hr pH test and manometry?*  Yes No

9. Have you ever been diagnosed with Barrett's Oesophagus?*  Yes No

10. Have you been diagnosed with a hiatal hernia?*  Yes No

11. Have you had gastro-oesphageal surgery, anti-reflux surgery or surgery for oesophageal/stomach cancer?*  Yes No

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