Mydyspepsia Survey | Survey  
Your responses will be kept strictly confidential so please be as accurate as possible. The survey should take about 10 minutes to complete. Your responses will be scored immediately for you to review.


Demographics
What is your date of birth?

What is your gender?
Male
Female

What is your current marital status?
single (never married)
married (or common-law)
divorced (or separated)
widowed

What is the HIGHEST level of education you have attained?

What is your before-tax annual income? (optional)
USD CDN Euro

In what country do you live?

In what state/province do you live? (US and CDN residents)

Which of these symptoms is your MAIN gastrointestinal complaint?
Upper abdominal pain (pain above the navel/stomach pain)
Nausea or vomiting or abdominal bloating with visible distention (noticeably swollen belly)
Heartburn (pain or burning radiating up to the throat) or acid regurgitation (sour taste/stomach contents coming back up)
I don't have any of these symptoms

Which of these health-care providers have you seen because of your upper gastrointestinal symptoms?
My family doctor
A specialist (Gastroenterologist)
Alternative/complimentary medicine practitioner
None, I have only talked to friends or family about my symptom(s)
None, I have not talked to anyone about my symptom(s)

When was the last time you reviewed any patient education materials (pamphlets, books, videos, web-sites) to learn more about your symptom(s)?
Within the last week
Within the last month
Within the last six months
Within the last year
Over a year ago
Never

Has your doctor EVER told you that you have ANY of the following?
PLEASE CHECK ALL THAT APPLY.
Gastroesophageal reflux disease (GERD) or Reflux
Gastritis (stomach inflammation)
Dyspepsia (indigestion)
Helicobacter pylori infection
Gallstones
Lactose intolerance
Stomach cancer
Dysmotility (motility disorder)
Esophagitis
Peptic ulcer disease (Ulcers)
Chronic cough
Pancreatitis
Celiac disease
Irritable bowel syndrome (IBS)
Other:
My gastrointestinal symptoms have not yet been diagnosed

Are you currently taking any prescription or non-prescription medication for your upper gastrointestinal symptom(s)?
No Yes; please specify:



Dyspepsia and GERD Knowledge Questionnaire

Choose the best answer or check NOT SURE if you aren't sure of the answer.

1. Which one of the following statements about Helicobacter pylori (H. pylori) is FALSE?
It can be detected using a Urea Breath Test
H. pylori is thought to cause 50% of ulcers
Those with H. pylori may not have symptoms of dyspepsia
Not sure

2. Proton Pump Inhibitors (PPIs) are NOT intended to treat:
Gastroesophageal reflux disease (GERD)
Dysmotility
H. pylori infections
Not sure

3. The Antrum is:
Part of the stomach
Part of the small bowel
Part of the esophagus
Not sure

4. A neutrophil is:
A type of white blood cell
The substance ingested for an upper G.I. Series
The lining of the stomach wall
Not sure

5. Which one of the following is NOT a symptom of GERD?
Regurgitation
Heartburn
Diarrhoea
Hoarse voice
Not sure

6. When is combined antibiotic and acid-reducing therapy recommended?
When you have an ulcer, but not H. pylori
When you have aerophagia
When you have an H. pylori infection and an ulcer
Not sure

7. In which one of the following ways does functional dyspepsia differ from peptic ulcer disease?
Symptoms are much milder with functional dyspepsia
Examinations reveal no signs of organic disease in functional dyspepsia
Functional dyspepsia is easily cured
Not sure

8. Which one of the following statements is TRUE?
A hiatal hernia may be worse with pregnancy or obesity
Hiatal hernias may be caused by GERD
A hiatal hernia may be a contributing factor in developing an H. pylori infection
Not sure

9. Which one of the following can interfere with the accuracy of a Urea Breath test?
Eating spicy foods the day before the test
Taking ulcer medication in the 2 weeks before the test
Performing the test while lying down
Not sure

10. Why does H. pylori result in ulcers in some people?
Because some lack an enzyme called pepsin which protects against H. pylori infiltration.
Because, over time, the spiral shaped bacteria can burrow through the stomach wall creating an ulcer.
Because the immune system attacks H. pylori, weakening the stomach lining and making it susceptible to acid.
Not sure

11. Which one of the following can IMPROVE symptoms of GERD?
Peppermint or spearmint
Taking iron or potassium supplements
Elevating the head of your bed by 6 inches
Not sure

12. Which one of the following is NOT a complication of ulcers?
Damaged blood vessels and bleeding
Anemia
A hole (perforation) in the stomach or duodenum
Difficulty swallowing
Lactose intolerance
Not sure

13. Which one of the following causes relatively little gas?
Fibre
Meat
Carbohydrates
Not sure

14. Which one of the following statements is FALSE?
Rates of gastric (stomach) cancer have been increasing in western societies in the last 50 years
H. pylori is believed to be responsible for 40-60% of gastric cancers
Clearing an H. pylori infection can result in the complete disappearance of gastric MALToma tumours (lymphomas) without any other therapies
Not sure

15. If you have an erosion in your stomach then you have:
A deep ulcer leading to perforation
A shallow ulcer
A hole in your stomach lining at least 3 cm in diameter
Not sure

16. Which statement about the long-term use of PPI medication is TRUE?
Once your optimal dose is determined, it can likely remain steady over many years
PPIs are not recommended for long-term use, but only for the first 4-8 weeks of therapy
PPIs can be used for many years provided the dose is steadily increased over time to compensate for increased drug tolerance
Not sure

17. Research has found that those who smoke:
Are more likely to develop ulcers
Are more likely to have an H. pylori infection
Are just as likely to die of ulcers as non-smokers
Not sure

18. Long term use of which medication can result in the harmful build-up of magnesium, and a change in the way the body breaks down and uses calcium?
Proton Pump Inhibitors (PPIs)
Antacids
H2 blockers
Not sure

19. What does a 24-hour pH monitoring test assess?
The amount of time it takes food to move through the digestive tract
The episodes of reflux and the types of activity associated with symptoms
The esophagus' susceptibility to acid
Not sure

20. What can happen when someone has a hiatal hernia?
The opening from the stomach to the small bowel becomes narrowed causing acid build-up in the stomach
The muscle connecting the esophagus to the stomach allows acid to flow into the esophagus
The esophagus narrows causing acid retention and difficulty in swallowing
Not sure


Quality of Life (SF-12 Health survey)
In general, would you say your health is:
Excellent Very good Good Fair Poor
 
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
Yes, limited a lot
Yes, limited a little
 No, not limited
Moderate activities, such as moving a table, a vacuum cleaner, bowling or playing golf.
Climbing several flights of stairs.
 
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
Yes
No
Accomplished less than you would like
Were limited in the kind of work or other activities
 
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems?
 
Yes
No
Accomplished less than you would like
Didn't do work or other activities as carefully as usual
 
During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
 
Not at all Slightly Moderately Quite a bit Extremely
 
These questions are about how you feel and how things have been with you during the past 4 weeks. For each question please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks:
 
 
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
Have you felt calm and peaceful
 
Did you have a lot of energy
 
Have you felt downhearted and blue
 
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with you social activities (like visiting with friends, relatives, etc.)?
 
 
All of the time
Most of the time
A good bit of the time
A little of the time
None of the time
  
 
 



Gastrointestinal Symptom Rating Scale (GSRS)

Please choose the answer that best describes how you have been feeling during the past week.

1. Have you been bothered by stomach ache during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

2. Have you been bothered by heartburn during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

3. Have you been bothered by hunger pains in the stomach during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

4. Have you been bothered by acid reflux during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

5. Have you been bothered by nausea during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

6. Have you been bothered by rumbling in your stomach during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

7. Has your stomach felt bloated during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

8. Have you been bothered by belching during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

9. Have you been bothered by breaking wind during the past week?
No discomfort at all
Minor discomfort
Mild discomfort
Moderate
Moderately severe
Severe
Very severe

Please provide the following information to complete the survey:
E-mail address
Confirm e-mail address

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First name
Last name
Phone number
Street Address
City
Postal Code

From time to time, we will send information and updates. Would you be interested in receiving these updates?
No
Yes, contact me by email
Yes, mail me information


Please complete the following to help us better understand your information (and treatment) needs or go to the end to SUBMIT your survey.


1. How often do you suffer from acid-related disorders?
Several times per day
3-4 times per week
1-2 times per week
2 or less times per month
Never

2. How do you treat your acid-related disease? (check all that apply)
Prescription medication – go to 4
Over the counter medication (purchase without prescription)
Both
Other – go to 4
Never

3. How often do you treat your acid-related disease with over the counter medications (purchased without a prescription)?
Several times per day
3-4 times per week
1-2 times per week
2 or less times per month
Never

3A. Please select the over the counter medications that you are taking from the following list (check all that apply).
TUMS®
Rolaids®
Pepto-Bismol®
Maalox®
Gaviscon®
Zantac®
Pepcid®
Other

4. How does your condition impact your daily life?
Not at All
Sometimes
Weekly
Daily

Now that you have completed the survey, click the “SUBMIT” button and you will receive confirmation that your entry has been successfully received.