---
title: Achalasia Screening Questionnaire Form Template | Paperform
description: Professional achalasia screening form with dysphagia assessment, weight tracking, and esophageal symptom evaluation for gastroenterology practices and medical clinics.
url: "https://paperform.co/templates/achalasia-screening-questionnaire"
type: static
generatedAt: "2026-03-28T00:42:57.895Z"
---

[← Back to free form templates](/templates/)    ![Achalasia Screening Questionnaire](https://img.paperform.co/fetch/f_webp/https://d3gw2uv1ch7vdq.cloudfront.net/content/form_templates/assets/achalasia-screening-questionnaire.png)
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### Achalasia Screening Questionnaire: Streamline Your Gastroenterology Assessments

Achalasia is a rare esophageal motility disorder that can significantly impact quality of life, but early screening and proper assessment can make all the difference. This **Achalasia Screening Questionnaire** template helps gastroenterology practices, primary care physicians, and medical clinics systematically evaluate patients presenting with dysphagia, regurgitation, and chest pain.

#### Designed for Healthcare Professionals Who Care About Thorough Assessment

Whether you're a gastroenterologist, physician, nurse practitioner, or healthcare administrator, this form streamlines the patient intake process by capturing critical symptom data, medical history, and risk factors in one organized questionnaire. The template includes dysphagia severity assessment, weight loss tracking, symptom duration, and previous diagnostic testing—all structured to help you determine if esophageal manometry or further specialized consultation is warranted.

#### Built on Paperform: More Than Just Data Collection

With Paperform, you're not just collecting information—you're creating a professional patient experience that reflects your practice's standards. This template uses conditional logic to adapt questions based on patient responses, ensuring you gather relevant details without overwhelming respondents. Plus, with Paperform's GDPR and SOC 2 Type II compliance, you can trust that sensitive health information is handled securely.

Once submissions come in, connect your form to your practice management system, send data to your EHR via integrations, or use [Stepper](https://stepper.io) to automatically route urgent cases to your gastroenterology team for priority follow-up. You can even use [Papersign](https://papersign.com) to send consent forms for manometry procedures or specialist referrals directly after screening.

#### Perfect for Gastroenterology Practices, Medical Clinics, and Specialist Referrals

This achalasia screening template is ideal for gastroenterology practices handling esophageal motility disorders, primary care physicians triaging dysphagia cases, and medical centers offering specialized GI services. Customize the questions, add your practice branding, and embed the form directly on your website or patient portal for seamless digital intake that saves time and improves diagnostic accuracy.
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