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…

Heartburn Symptom Record

Topic Overview

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?

Credits

Current as ofJune 26, 2019

Author: Healthwise Staff
Medical Review: William H. Blahd, Jr., MD, FACEP – Emergency Medicine
Adam Husney, MD – Family Medicine
Kathleen Romito, MD – Family Medicine

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