8/19/2019 Gsrs Questionnaire

1/2

GSRS Questionnaire for Pre and Post Op Bariatric Surgery Patients

Sleeve Bypass Lap Band Pre Op Post Op How Long Ago?______________________

atient Name________________________________________________ Date: ____________________

Please answer every question by encircling ONLY ONE response that best describes how you have felt during the past 2 weeks:

1. Heartburn. Representing retrosternal discomfort of burning sensation

a. How much has heartburn bothered you on a daily basis?

Not at all1

Mild2

Moderate3

Seere!

b. How often hae you e"perienced heartburn?

Neer #

$nce a month1

$nce a wee%2

2&! times a wee%3

'aily

!

2. Regurgitation. Representing sudden regurgitation of acid gastric content

a. How much has regurgitation bothered you on a daily basis?

Not at all1

Mild2

Moderate3

Seere!

b. How often hae you e"perience regurgitation?

Neer #

$nce a month1

$nce a wee%2

2&! times a wee%3

'aily

!

3. Abdominal distention. Representing bloating with abdominal gas (feeling bloated and gassy in your abdomen)

a. How much has epigastric fullness(upper abdominal fullness) bothered you on a daily basis?

Not at all1

Mild2

Moderate3

Seere!

b. How often hae you e"perienced epigastric fullness (upper abdominal fullness)?

Neer #

$nce a month1

$nce a wee%2

2&! times a wee%3

'aily

!

!. Dysphagia. Representing difficulty or discomfort in swallowing or the sensation of a lump in the throat.

a. How much has dysphagia (difficulty or discomfort in swallowing) bothered you on a daily basis?

Not at all1

Mild2

Moderate3

Seere!

b. How often hae you e"perienced dysphagia (difficulty or discomfort in swallowing)?

8/19/2019 Gsrs Questionnaire

2/2

GSRS Questionnaire for Pre and Post Op Bariatric Surgery Patients

Sleeve Bypass Lap Band Pre Op Post Op How Long Ago?______________________

Neer #

$nce a month1

$nce a wee%2

2&! times a wee%3

'aily

!

*. Coughing. Representing the need to e"pel air from the lungs suddenly and noisily+ often to %eep the respirator passages free ofirritating material

a. How much has coughing bothered you on a daily basis?

Not at all1

Mild2

Moderate3

Seere!

b. How often hae you coughed?

Neer #

$nce a month1

$nce a wee%2

2&! times a wee%3

'aily

!

!