Introduction

I am an intern at McTimoney College of Chiropractic and would be extremely grateful if you could spare a few minutes to assist me in compiling the data I need for my research dissertation.

The aim of the research is to find out if people with neck pain and stiffness are more likely to have heartburn (also sometimes called GORD) than the general population.

Gastric reflux is a growing problem in the Western world. Research has focused mainly on anti-acid medication and surgery. However, there's little research on how the problem might begin. In particular, how the nerves controlling the valve at the stomach entrance might be affected by the roots of those nerves in the neck, due to neck problems.

People often go to chiropractors for treatment of neck pain. If neck problems do affect the symptoms of heartburn we may be able to consider routinely using chiropractic to help relieve the symptoms.

To participate, if you have neck problems please simply fill out the questionnaire. The survey is completely anonymous and by kindly completing and submitting it you are giving your consent for the anonymous data you provide to be analysed and presented in my research dissertation.

Thank you for your help,
Graham

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* 1. Have you had chiropractic or osteopathic treatment on your neck?

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* 2. What is your gender?

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* 3. How old are you?

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* 4. What is your height in metres?

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* 5. What is your weight in kg

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* 6. How many cigarettes do you smoke a day?

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* 7. How often do you have 5 fruit and veg?

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* 8. How often do you walk for at least 15 mins?

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* 9. Do you have any of the following allergies? (Tick all that apply)

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* 10. Do you frequently have any of the following symptoms? (Tick all that apply)

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* 11. Have you had your symptoms for 6 months or more?

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* 12. Do you take medication for these symptoms (prescribed or over the counter)?

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* 13. Do you have any of the following? (Tick all that apply)

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* 14. Has your GP referred you for heart (cardiovascular) or lung (pulmonary) investigations?

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* 15. Do you have heartburn, indigestion or acid reflux

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* 16. Do you have hiccups

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* 17. Do you have irritable bowel symptoms

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* 18. Do you have neck pain

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* 19. Do you have neck stiffness

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* 20. Over the past week, how would you rate your neck pain from 0 (no pain) to 10 (worst possible pain)?

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* 21. Over the past week, how much has your neck pain interfered with your daily activities from 0 (no interference) to 10 (unable to carry out activities)?

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* 22. Over the past week, how much has your neck pain interfered with your ability to take part in recreational, social, and family activities? From 0 (no interference) to 10 (unable to carry out activities).

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* 23. Over the past week, how anxious have you been feeling, from 0 (not at all anxious) to 10 (extremely anxious)?

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* 24. Over the past week, how depressed have you been feeling from 0 (not at all depressed) to 10 (extremely depressed)?

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* 25. Over the past week, how has your work been affected by your neck pain, both inside and outside your home? From 0 (made it no worse) to 10 (made it much worse).

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* 26. Over the past week, how much have you been able to control your neck pain without medication? From 0 (completely control it ) to 10 (no control at all).

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* 27. Has your neck pain been clinically diagnosed?

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* 28. Over the past week, how often did you have heartburn (burning feeling behind breast bone)?

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* 29. Over the past week, how often did you have stomach contents move up into your throat or mouth (regurgitation)?

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* 30. Over the past week, how often did you have a pain in the centre of the upper stomach?

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* 31. Over the past week, how often did you feel the need to be sick (nausea)?

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* 32. Over the past week, how often did you have difficulty getting a good night’s sleep because heartburn or regurgitation kept you awake?

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* 33. Over the past week, how often did you take over-the-counter medication for heartburn or regurgitation, other than what the GP told you to take?

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* 34. Do you regularly take any of the following? (Tick all that apply)

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