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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?
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Impact of symptoms | - Were you unable to sleep?
- Were you unable to go to work?
- Were you unable to perform your normal activities?
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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?
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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.
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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?
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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.
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.