Heartburn Symptom Record

Record

Answer questions

Date and time of day: ________

Date and time of day: ________

Date and time of day: ________

Symptoms

• What were your symptoms?
• How long did the heartburn last?
• Do you have any other symptoms, such as asthma, hoarseness, or stomach pain?
• Does pain radiate to another part of your body?

Impact of symptoms

• Were you unable to sleep?
• Were you unable to go to work?
• Were you unable to perform your normal activities?

Possible triggers of symptoms

• Are you taking any medicines?
• Did exercise make your symptoms worse?
• What did you eat? What did you drink?
• Did you smoke before this episode?
• Were you under stress?
• Were you lying down or bending over during the episode?

Treatment

• Did you take any medicines—over-the-counter or prescription—to relieve the heartburn? Record all treatments, including antacids, herbal remedies, and home remedies.

Outcome of treatment

• Did the medicine provide complete relief? If yes, how long did the relief last?
• Did your symptoms persist even though you took the medicine as indicated?