Fill out this form to identify your risk level for esophageal precancer and cancer.

First Name *

Last Name *

Phone *

Email *

I agree to receive email and SMS messages from Beltline Health Weight Loss Solutions.

Each question is associated with a risk factor, if you respond ‘yes’ to three or more questions you may be at increased risk of developing disease.

Do you have acid reflux/heartburn and or take any medication for acid reflux/heartburn symptoms? *

Yes

Do you have a family history of Barrett’s esophagus or esophageal cancer? *

Yes

Are you 50 years or older? *

Yes

Are you male? *

Yes

Are you overweight? *

Yes

What best describes you? *

Asian or Pacific Islander

Black or African American

Hispanic or Latino

Native American or Alaskan Native

White or Caucasian

Multiracial or Biracial

A race/ethnicity not listed here

Do you or have you ever smoked tobacco products? *

Yes

Have you had occupational or environmental exposure? (smoke inhilation/fire/chemicals) *

Yes

Do you have any of these symptoms? (check all that apply)

Regurgitation

Chest Pain

Nausea after eating

Sour taste in mouth

Coughing, choking or wheezing

Difficulty swallowing

Hiccups

Belching or burping excessively

Hoarseness or change in voice

Sore Throat

Feeling that food is stuck behind the breastbone

Other symptoms (please explain):

How frequently do you experience symptoms? *

One or more times per week

Less than once per week

How many years have you had chronic GERD, acid reflux or heartburn? *

Less than 5 years

5 years or more

By submitting this form, you are giving your consent to receive SMS messages and/or emails from our company. If you wish to unsubscribe, kindly follow the instructions provided in our communications. Please note that standard message and data rates may apply for SMS. Rest assured that your information is secure and will not be shared with any third parties.