Heartburn Record

When you experience chronic heartburn, the first step to controlling your heartburn is to record what may trigger your attacks, the severity of the attacks, how your body reacts, and what gives you relief. The next step is to take this information to your doctor so the both of you can determine what lifestyle changes you will need to make and what treatments will give you maximum relief.

You can use the record below. If you would like a color chart, you can find a printable version if you go here. If you prefer a black and white chart, you can print it if you go here. The important thing to do is record the information suggested below for at least a week, and then discuss the results with your doctor.

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?	.