Print and Track Your Heartburn Every Day

To better understand what may be causing your heartburn and when, you may consider tracking your food intake, as well as the times when you experience heartburn. This information can be valuable in helping your doctor diagnose the best course of heartburn treatment for you.

Print out this chart:

Then, each time you experience heartburn symptoms, keep a record of the details:

• When did the heartburn symptom(s) start?
• How long did the symptoms last?

• What did you eat and/or drink just prior to these heartburn symptoms occurring?

• Did you experience any discomfort? If so, what type and where?

• How would you rate the overall severity and discomfort on scale of 1 to 10?

• Did the symptoms cause you to stop doing an activity? If so, what?

• What did you do to immediately alleviate the symptoms? Lie down, stand up, etc.?
• Did these actions help at all?

• Did you take any form of over-the-counter or prescription medication to treat these symptoms? If so, which ones?

Save a printer-friendly version of this diary entry. Reuse this form each time you experience heartburn.