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GERD Symptom & Treatment Progress Tracker

Daily Monitoring Chart for Gastroesophageal Reflux Disease Management

Gastroenterology

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Template Content

Last updated: Mar 24, 2025

Patient Information

Name: ___________________ Date Started: //___

Daily Symptom Severity Scale

0 = None | 1 = Mild | 2 = Moderate | 3 = Severe

Week of: //___

Symptoms Mon Tue Wed Thu Fri Sat Sun
Heartburn ___ ___ ___ ___ ___ ___ ___
Regurgitation ___ ___ ___ ___ ___ ___ ___
Chest Pain ___ ___ ___ ___ ___ ___ ___
Difficulty Swallowing ___ ___ ___ ___ ___ ___ ___

Dietary Triggers Noted

  • □ Spicy Foods
  • □ Citrus
  • □ Caffeine
  • □ Chocolate
  • □ Fatty Foods
  • □ Other: ____________

Lifestyle Modifications Tracked

  • □ Elevated head of bed
  • □ Avoided lying down for 3 hours after meals
  • □ Maintained healthy weight
  • □ Stopped smoking
  • □ Reduced alcohol intake

Medication Adherence

Medication Name: ________________ Dosage: ________________ Taken as prescribed: □ Yes □ No

Notes

Symptoms worse with: ________________ Symptoms better with: ________________

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