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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 of: June 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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