| N˚ | Questions/Links | Details | Answers | ||
| I—Socio-demographic and economic characteristics | |||||
| 1 | Identification number |
| /_____/ | ||
| 2 | Collection date | /__/ /__/ 2019 |
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| 3 | Address/phone number |
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| 4 | Nationality | 1. Beninese 2. Others to be specified | /___/ | ||
| 5 | Sex | 1. Male 2. Female | /___/ | ||
| 6 | Age (ans) |
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| 7 | Level of education | 1. Primary 2. Secondary 3. University 4. Literate 5. None | /___/ | ||
| 8 | Socio-professional status | 1. Household appliance 2. Craftsman/Worker 3. Shopkeeper/Dealer 4. Faemer/Breeder 5. Civil servant 6. Pupil/Student 7. Other (Please spécify)… | /___/ | ||
| 9 | Marital status | 1. Single 2. Married 3. Divorced 4. Widowed | /___/ | ||
| 10 | Religion | 1. Christian 2. Muslim 3. Endogenous | /___/ | ||
| 11 | Monthly income (FCFA) | 1. <40,000 2. 40,000 - 100,000 3. ≥100,000 | /___/ | ||
| II—Clinical characteristics | |||||
| 12 | Clinical manifestations of GERD | 1. Isolated heartburn 2. Isolated regurgitation 3. Heartburn and regurgitation 4. No | /___/ | ||
| 13 | ENT manifestations of GERD | 1. Dysphonia (chronic hoarseness) 2. Pharyngeal burning and/or paresthesia 3. Sensation of a lump in the throat 4. Halitosis 5. Sialorrhea 6. Earache 7. None | /___/ | ||
| 14 | Onset of symptoms (days) | /__/ /__//__/ |
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| 15 | Weekly symptom frequency | ≤twice a week ≥twice a week | /___/ | ||
| 16 | Period of occurrence in the nycthemeral period | 1. Diurnal 2. Nocturnal 3. Diurnal et nocturnal | /___/ | ||
| 17 | Warning signs | 1. Yes 2. No | /___/ | ||
| History and risk factors | |||||
| 18 | I feel tense or irritated | 0. Never 1. Once in a while 2. Often 3. Most of the time | /___/ | ||
| 19 | I enjoy the same things as before | 0. Yes, just as much 1. Not so much 2. Only a little 3. Almost more | /___/ | ||
| 20 | I have a feeling of fear as if something horrible is going to happen to me | 0. Not at all 1. A little, but I’m not worried 2. Yes, but it’s not too serious 3. Yes, very serious | /___/ | ||
| 21 | I laugh easily and look on the bright side | 0. As much as in the past 1. Not as much as before 2. Definitely less than before 3. Not at all | /___/ | ||
| 22 | I’m worried | 0. Very occasionally 1. Occasionally 2. Quite often 3. Very often | /___/ | ||
| 23 | I’m in a good mood | 0. Most of the time 1. Quite often 2. Rarely 3. Never | /___/ | ||
| 24 | I can sit quietly doing nothing and feel relaxed | 0. Yes, whatever happens 1. Yes, in general 2. Rarely 3. Never | /___/ | ||
| 25 | I feel like I’m in slow motion | 0. Never 1. Sometimes 2. Very often 3. Almost always | /___/ | ||
| 26 | I have feelings of fear and a knot in my stomach | 0. Never 1. Sometimes 2. Quite often 3. Very often | /___/ | ||
| 27 | I’ve lost interest in my appearance | 0. I pay as much attention to it as in the past 1. I may not pay as much attention anymore 2. I don’t pay as much attention as I should 3. Not at all | /___/ | ||
| 28 | I’m restless and can’t keep still | 0. Not at all 1. Not so much 2. Somewhat 3. Yes, that’s exactly the case | /___/ | ||
| 29 | I’m looking forward to doing some things | 0. As much as before 1. A little less than before 2. Much less than before 3. Almost never | /___/ | ||
| 30 | I experience sudden feelings of panic | 0. Never 1. Not very often 2. Quite often 3. Really very often | /___/ | ||
| 31 | I can enjoy a good book or a good radio or television program | 0. Often 1. Sometimes 2. Rarely 3. Very rarely | /___/ | ||
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| Total points |
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| 32 | Psychological profile | 1. No anxiety 2. Probable anxiety 3. Definite anxiety | /___/ | ||
| 33 | Asthma | 1. Yes 2. No | /___/ | ||
| 34 | Diabetes mellitus | 1. Yes 2. No | /___/ | ||
| 35 | Scléroderma | 1. Yes 2. No | /___/ | ||
| 36 | Chronic obstructive pulmonary disease | 1. Yes 2. No | /___/ | ||
| 37 | Taking non-steroidal anti-inflammatory drugs/acetylsalicylic acid | 1. Yes 2. No | /___/ | ||
| 38 | Alcohol consumption | 1. Yes 2. No | /___/ | ||
| 39 | Tobacco consumption | 1. Yes 2. No | /___/ | ||
| 40 | Excessive consumption of fats | 1. Yes 2. No | /___/ | ||
| 41 | Excessive consumption of spices | 1. Yes 2. No | /___/ | ||
| 42 | Consumption of soft drinks | 1. Yes 2. No | /___/ | ||
| 43 | Foods that trigger symptoms | ................................................... |
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| Anthropometric parameters | |||||
| 44 | Weight (kg) | …………………………………. |
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| 45 | Size (cm) | ……………………………………. |
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| 46 | BMI (Kg/m2) | ……………………………………. |
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| 47 | Waist circumference (cm) | /__/ |
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