Infant Acid Reflux Questionnaire

The Infant Acid Reflux Questionnaire is here for you to take as many times as you'd like. You can print out the PDF version so you can keep a reflux journal to show your doctor or for your own records. Taking time to answer these simple questions could help you understand what’s happening to your baby and if your child is at risk of suffering from infant reflux. It also helps us to understand what's happening with your baby.

The Infant reflux questionnaire was developed by a group of well respected physicians and researchers , then validated in clinical studies. It is a good tool for not only identifying if reflux is present but also for following progress.  The more you document what's happening with your baby the better it is for you to address treatment options.

At the end of the questionnaire you have the option to request a consultation of how to treat your baby if in fact your baby is suffering from infant acid reflux.

We’re working hard to help make babies bellies better. This information will help us, and help us help other babies too!

Thank you!
The Infant Acid Reflux Solutions Team

Printable Version for your Infant Acid Reflux Journal

This Form cannot be submitted until the missing fields (labelled below in red) have been filled in
Infant Acid Reflux Questionnaire
Please note that all fields followed by an asterisk must be filled in.
First Name*
E-Mail Address*
Country*	CountryUnited StatesCanada----------------AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntiguaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyIvory CoastJamaicaJapanJordanKazakhstanKenyaKiribadiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoFederated States of MicronesiaMoldovaMonacoMongoliaMontserratMoroccoMontenegroMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaS. Georgia and S. Sandwich Isls.Saint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamUS Virgin IslandsWallis and Futuna IslandsWestern SaharaYemenYugoslavia (former)ZaireZambiaZimbabwe
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How old is your child?*
How much does your child weigh?*
When did your suspicions of infant reflux begin?*
If your child has seen a medical doctor, what did they prescribe for your child? Be specific. Name of product, dose, capsule, tabs, etc:*
If currently on medication, what? Be specific. Name of product, dose, capsule, tabs, etc:*
During eating or feedings, place a check for each symptom below that applies to your baby.*
Irritable during eating Refusal to eat Only eats small amounts per feeding Gags when eating Arches back during feeding Has difficulty swallowing None of the above
After eating or feedings, place a check for each symptom below that applies to your baby.*
Suffers from colic Unusually frequent hiccups Wet Burps or liquid comes up during burping Spitting up during feeding Spitting up after feeding Frequent vomiting Acid odor to the vomit None of the above
Regarding sleeping habits, place a check for each symptom below that applies to your baby.*
Poor sleeping habits Suffers from Apnea or Snoring Has spells of not breathing None of the above
Generally symptoms, place a check for each symptom below that applies to your baby.*
Coughing without signs of a cold Crying suddenly Crying constantly Not growing Losing weight Wheezing sound during breathing Repetitive ear infections Repetitive lung infections Repetitive Sinusitis None of the above
Vomiting/Regurgitation: Within the last 24 hours, how many times did your baby spit up or vomit? (Anything coming into or out of the mouth)*
None 1-3 Times 4-6 Times More than 6 times
Vomiting/Regurgitation: Within the last 24 hours, how much spit up did your baby spit up or vomit? (Anything coming into or out of the mouth)*
None Less than 1 tablespoon 1 tablespoon to 2 fluid ounces 2 fluid ounces to half of what you fed your child Half of what you fed your child or more
Vomiting/Regurgitation: Within the last 24 hours, did spitting up seem uncomfortable to your child? (crying, fussing, irritability, arching)*
Yes No
Irritability or Fussiness: Within the last 24 hours, did your child cry or fuss during feedings?*
Yes No
Irritability or Fussiness: Within the last 24 hours, how long did your child cry during feeding or within 1 hour after feeding?*
Not at all Less than 10 minutes 10 minutes to 1 hour More than 1 hour but less than 3 hours 3 hours or more Constant and uncontrollable crying
Within the last 24 hours, how many episodes of back arching occurred?*
None 1 to 3 times 4 to 6 times More than 6 times
Feeding Refusal: Within the last 24 hours, how many times did your child refuse feeding even when hungry?*
None 1 to 3 times 4 to 6 times More than 6 times
Feeding Refusal: Within the last 24 hours, how many times did your child stop feeding even when hungry?*
None 1 to 3 times 4 to 6 times More than 6 times
Respiratory Symptoms: Within the last 24 hours, did your child have a cold or fever?*
Yes No
Respiratory Symptoms: Within the last 24 hours, did your child have a cough without a cold?*
Yes No
Respiratory Symptoms: Within the last 24 hours, how much of the time did your child have noisy breathing without a cold?*
None of the time About a quarter of the time About half of the time All or almost all of the time
Respiratory Symptoms: Within the last 24 hours, did your child have noisy breathing while breathing outwards?*
Yes No
Respiratory Symptoms: Within the last 24 hours, did your child's breathing have a wheezy or whistling sound?*
Yes No
Respiratory Symptoms: Within the last 24 hours, did your child have noisy breathing while breathing in?*
Yes No
Respiratory Symptoms: Within the last 24 hours, did your child's breathing have a croupy or barky sound?*
Yes No
Respiratory Symptoms: Within the last 24 hours, did your child stop breathing or turn blue or purple?*
Yes No
An additional notes or comments you'd like to add or that you feel we should know.
Do you want to be contacted by phone for a free phone consultation? (IF YES PLEASE INCLUDE PHONE NUMBER IN TOP PORTION OF THE QUESTIONAIRE)
Yes No
Please enter the word that you see below.

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