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Reflux Record

  

The first step to controlling heartburn is identifying what may trigger your attacks and how your body responds to those factors. The next is determining which lifestyle changes and treatments may offer relief for you. This record will help you chart the frequency and severity of attacks, if you decide to see your health care professional or pharmacist for advice, bring this record to serve as a reference during your visit.

Record the date, time of occurrence, factors that seem to contribute to your heartburn and any symptoms that might be related. Then write down what you do to relieve the heartburn and whether and how long it works. Complete a separate column for each episode and answer as many questions as you can for each episode.

To assist you with keeping track of your heartburn symptoms we have developed a Personal Reflux Diary which you can get here as an Adobe® Acrobat® Portable Document Format (PDF) document or you can request a brochure that contains this and other information at:

The National Heartburn Alliance
303 East Wacker Drive, Suite 440
Chicago, IL 60601
Phone: (877) 471-2081
Email: nhbainformation@heartburnalliance.org

After examining your symptom history be prepared to answer the following questions with your health care professional.

QUESTION	RESPONSE
How often does your heartburn occur?
Is there a typical time of day for your attacks?
Is your medicine providing relief? How long does the relief typically last?
Is your heartburn affecting your daily activities?