How often do you experience heartburn? (Choose one.)
Every day
At least twice a week
At least once a month
Infrequently

Have you seen a doctor about your heartburn?
Yes No

Are you taking any medicine?
Yes - over-the-counter
Yes - prescription
No medicine

What over-the-counter medication are you taking to treat your heartburn?
Maalox, Tums, AlkaSeltzer or Gaviscon
Tagamet HB
Pepcid AC
Zantac 75
Axid
Other:

What prescription medication are you taking to treat your heartburn?
Tagamet (Cimetidine)
Pepcid (Famotidine)
Zantac (Ranitidine)
Axid (Nizatidine)
Prilosec (Omeprazole)
Prevacid (Lansoprazole)
Propulsid (Cisapride)
Reglan (Metaclopramide)
Other:

Are you still having symptoms on the medication you're currently taking?
Yes No

What is your age?
Under 18
18-24
25-34
35-44
45-60
Over 60

Gender
Male Female

How did you hear about this Web site? (Choose one.)
Television
Newspaper/magazine
Family member/friend
Doctor
Internet-related (i.e., links, e-mail, newsgroup)
Other:

Would you like to be notified about opportunities to participate in no-cost research studies about heartburn/health issues?
Yes No

Would you like to receive additional no-cost information that may become available from the College in the future that generally matches your areas of primary interest?
Yes No

Would you like to receive additional suitable, no-cost, information that may become available from pharmaceutical companies in the future that generally matches your areas of interest?
Yes No

May the College contact you in the future to secure you thoughts and feedback about heartburn?
Yes No