Dose the patient being treated have any of the following conditions?

• Under 2 years old.

• Heartburn that continues during or after an over the counter treatment (OTC treatments are not working).

• Very severe, agonizing pain.

• Heartburn during sleep, or heartburn that is disrupting sleep.

• Heartburn more than two days per week for three months or more.

• Vomiting.

• Black tarry stools.

• Choking, coughing, wheezing, or hoarseness.

• Persistent nausea or diarrhea with onset of heartburn.

• Chest pain, jaw pain, or left arm or shoulder pain accompanied by sweating.

• Pregnancy or nursing.

• Pain when swallowing.

• Low magnesium levels.

• Have allergies to OTC medications used to treat heartburn.

• Taking prescription medications including warfarin, methotrexate, digoxin, clopidogrel, cilostazol, anti fungal medications, tacrolimus, mycophenolate mofetil, HIV medications, thyroid medications.

• Indigestion suddenly occurring to someone who is over 45 years old.

• Recent weight loss with no known cause.


Yes

No



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