Heartburn / GERD
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Record: Ask Yourself: Your Answer:
DURATION When did the symptoms begin? .
How long did the symptoms last? .
SYMPTOMS Was there pain? Reflux? Both? .
Sore and / or irritated throat? .
Have a persistent dry cough? .
Sour or bitter taste in your mouth? .
Difficult or painful swallowing? .
What was the most severe symptom? .
IMPACT Did the heartburn interfer with sleep? .
Did it interfer with daily activities? .
TRIGGERS What did you eat? Drink? .
Did you eat fast, gulping your food? .
Did you lay down right after eating? .
Taking any non-heartburn meds? .
TREATMENT Taking medication for heartburn? .
Did the medication provide relief? .
How long before relief of symptoms? .
Did your symptoms return? .
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Heartburn / GERD
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