Healthwise

Our Health Library information does not replace the advice of a doctor. Please be advised that this information is made available to assist our patients to learn more about their health. Our providers may not see and/or treat all topics found herein.

Heartburn Symptom Record

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: October 24, 2023

Author: Healthwise Staff
Clinical Review Board
All Healthwise education is reviewed by a team that includes physicians, nurses, advanced practitioners, registered dieticians, and other healthcare professionals.

Due to the threat of the COVID-19 (Coronavirus), we are taking precautionary measures to protect our staff and patients. We are implementing a temporary NO VISITOR policy at this time. Only patients or patients and their guardians will be allowed into the office. Please note, this is not to inconvenience anyone! The virus is a very real threat and it is essential that we stay healthy in order to provide needed care for our patients. If you are sick, we ask that you CALL the office to speak with a nurse before you come in. The nurse will provide specific instructions for you. Please DO NOT enter the office if you are sick (upper respiratory symptoms, fever, cough, or flu like symptoms). We are closely monitoring the situation and will update you as circumstances change. Thank you for your understanding!!