Burning feeling in your throat or chest (heartburn)
Bloating
Burping
The sensation of food being stuck in your throat
Bitter and/or sour taste in your mouth
Sore throat
Vomitting
Bloody or black stools
Are you overweight?
Yes
No
Do you drink caffeinated beverages?
Yes
Occasionally
No
Are you a smoker?
Yes
I only smoke occasionally
No
Do you drink alcohol?
Yes
I only drink occasionally
No
How old are you?
19 years or less
20 to 29
30 to 39
40 to 49
50 to 59
60 or more
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