GERD Symptom & Treatment Tracking Journal

Patient Information

Name: ___________________ Date Started: ___________________

Daily Symptom Tracker

Rate your symptoms (0-10 scale, 0=none, 10=severe)

Date: //___

• Heartburn: ___
• Regurgitation: ___
• Chest Pain: ___
• Difficulty Swallowing: ___
• Chronic Cough: ___
• Sleep Disruption: ___

Trigger Documentation

Foods Consumed Today

• Breakfast: ______________________
• Lunch: _________________________
• Dinner: ________________________
• Snacks: ________________________

Potential Triggers (check all that apply)

□ Spicy Foods □ Citrus □ Caffeine □ Alcohol □ Large Meals □ Late Night Eating □ Other: _____________

Medication Log

Lifestyle Modifications

Today I:

□ Elevated head of bed □ Waited 3 hours after eating before lying down □ Avoided tight clothing □ Maintained healthy weight activities □ Avoided identified trigger foods

Notes

Symptom patterns/observations: _____________________________

Weekly Review

Overall symptom improvement: □ Better □ Same □ Worse

Bring this journal to your next appointment