GERD Questionnaire
What a GERD questionnaire asks, with sample questions on reflux symptoms, heartburn medicines, and past care.
A GERD questionnaire records heartburn and reflux symptoms, the medicines taken for them, past endoscopies, and general health before a heartburn or reflux clinic visit. It's also called a reflux questionnaire or a heartburn clinic questionnaire.
GERD questionnaire, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a GERD questionnaire in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample GERD questionnaire questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- What is the main reason for this visit?Visit reason
- How long have you had this problem?Visit reason
- Do symptoms get worse after meals or lying down?Symptoms
- Do you have a chronic cough or hoarseness?Symptoms
- Which heartburn or reflux medicines do you take?Medicines
- Do you take ibuprofen or other NSAIDs?Medicines
- Have you had an upper endoscopy before?Past care
- Has a doctor diagnosed GERD or another digestive condition?Past care
- Do you use CPAP, BiPAP, or supplemental oxygen?Medical history
- What surgeries or hospital stays have you had?Medical history
- Do you smoke, vape, or use other nicotine?Lifestyle
- How much alcohol do you drink?Lifestyle
These are examples to read, not a form to fill in.
GERD questionnaire: FAQ
What does a GERD questionnaire ask?
The sample questions on this page are based on the Bingham Healthcare Heartburn and Reflux Center's new patient questionnaire. This page groups them into six areas: visit reason, symptoms, medicines, past care, medical history, and lifestyle.
Who fills in a GERD questionnaire, and when?
The patient, before the first visit. Bingham Healthcare asks new patients to send the completed packet before their first appointment is scheduled.
Is it the same as a heartburn clinic questionnaire?
It can be. The Bingham Healthcare form is a heartburn and reflux center's new patient packet that pairs a full health history with reflux symptom questions.
Does a GERD questionnaire ask about smoking and alcohol?
Yes. The Bingham Healthcare form asks about smoking, other nicotine use such as vaping, alcohol, and recreational drugs.
Does it ask about medicines other than heartburn ones?
Yes. The Bingham Healthcare form asks for every medicine with its dose and frequency, herbal and over-the-counter products, weight-loss medicines, and ibuprofen or other NSAIDs.
What happens after the form is completed?
The reflux team reviews the answers before the visit. AI Doctor collects them and does not suggest changes to heartburn medicines.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
