Heartburn Symptom Record

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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.

The Health Encyclopedia contains general health information. Not all treatments or services described are covered benefits for Kaiser Permanente members or offered as services by Kaiser Permanente. For a list of covered benefits, please refer to your Evidence of Coverage or Summary Plan Description. For recommended treatments, please consult with your health care provider.