| 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? | . |
