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Questionnaire
Name
Last Name
Phone Number
Email
Do you suffer at least three episodes of heartburn and/or regurgitation in a week for at least three months?
Yes
No
If not, please describe your health condition:
What is your age?
Are you generaly in a good health?
Yes
No
If not, please describe your health condition:
Have you gone through bariatric surgery?
Yes
No
For women, are you pregnant?
Yes
No
Are you overweight?
Yes
No
If yes, do you know your BMI
Have you ever taken anticid medications?
Yes
No
If yes, what is your medication
Which is the medical center that you prefer for conducting the study procedure?
Ichilov
Beilinson
Rambam
Bnai Zion
Submit
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