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Male Female Other

    1 - Do you get heartburn? *

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 2 - Does your stomach feel heavy after meals?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 3 - Does your stomach get bloated?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 4 - Do you notice that sometimes you rub your chest with your hand?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 5 - Do you ever feel sick after meals?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 6 - Do you get heartburn after meals?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 7 - Do you have an unusual (e.g. burning) sensation in your throat?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 8 - Do you feel full while eating meals?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 9 - Do some things get stuck when your swallow?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 10 - Do you get bitter liquid (acid) coming up in your throat?*

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 11 - Do you get heartburn if you bend over? *

  • Never
    Occasionally
    Sometimes
    Often
    Always

    • 12 - Please list any additional medical conditions, surgeries, or hospitalizations you have had.


    • 13 - Do you take any medicines, vitamins, or supplements?


    • Please list them here.

    14 - Please list any allergies you have.


    • Include any allergies to food, dyes, medications (including prescription medications and over-the-counter medications), insect venom, herbs, vitamins, supplements, and anything else.

    15 - Do you have a preferred treatment? *

  • Don't worry if you're not sure. Your doctor will help you pick the best one for you.
    No preference
    Famotidine|(Generic Pepcid®)|$30 per month, $50 every 3 months
    Omeprazole|(Generic Prilosec®)|$30 per month, $45 every 3 months
    Pantoprazole|(Generic Protonix®)|$30 per month, $45 every 3 months

    • 16 - Please enter preferred pharmacy information.*


    • Include a complete information where you would like to pick up your medication.

(Only JPEG, JPG, PNG or PDF format allowed and File size should be less than 10MB)

One Time Consulting Charges: $49.99 (USD)

The above payment is for consultation only and does not cover the cost of your medication. Top Health Center will only send your prescription to your pharmacy of choice.

Disclaimer
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