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: June 6, 2022

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

Top of the page
Next Section:
Credits

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.