Reflux Severity Index (RSI)

This questionnaire may help to identify symptoms of reflux.

Please answer each question.

Within the last month, how did the following problems affect you?

0-4 Rating System

0 = No problem
1 = Very mild problem
2 = Moderate or slight problem
3 = Moderate problem
4 = Severe problem
5 = Problem as bad as it can be


  • Date Format: MM slash DD slash YYYY

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