Doctor Conversation Guide

Here's a small step that can help you make the most of your time with your doctor. Just take a moment to answer the following 6 questions and print your answers. You'll have a handy conversation guide you can refer to when you discuss your condition with your doctor.

1. When do you feel heartburn symptoms? (Check all that apply) I have heartburn 2 or more times a week.
I have had frequent heartburn for more than 2 weeks.
I have frequent heartburn at night.

2. What other symptoms have you noticed? (Check all that apply) I feel liquid backing up into my throat when I lie down.
I wake up with a sour or bitter taste in my mouth.
I frequently have a sore throat in the morning.
I have hoarseness.
I have a persistent cough.
I experience wheezing.
Other

3. How long have you had these symptoms? Under 6 months
6 months to 1 year
Over 1 year

4. Which treatments have you tried for heartburn or acid reflux disease? (List all, or indicate "none.") Over-the-counter medicines like antacids

Prescription medicines

5. What foods or activities make your heartburn worse? (List 1 to 5 things. For example: coffee, fried foods, wearing tight clothes, lying down)

6. What else is helpful for your doctor to know? (Check all that apply) I avoid foods that may make my heartburn worse.
I'm a smoker.
I drink alcoholic beverages.
I eat big meals.
I often eat within 3 hours of bedtime.