Assessment
Questionnaire

Have a symptom?
See what questions
a doctor would ask.
 

Heartburn Assessment Questionnaire

Questions Your Doctor May Ask - and Why!

During a consultation, your doctor will use various techniques to assess the symptom: Heartburn. These will include a physical examination and possibly diagnostic tests. (Note: A physical exam is always done, diagnostic tests may or may not be performed depending on the suspected condition) Your doctor will ask several questions when assessing your condition. It is important to openly share any pertinent information to help your doctor make an accurate diagnosis.

It is also very important to bring an up-to-date list of all of your all medical conditions, medications including dosages, and names of numbers of any specialist you see.

Create your printable checklist by answering questions that your doctor may ask below:

Privacy Statement
No private information is transferred over the internet. Do not use the "Browser back button", as this may cause data loss.

  1. How long have you had heartburn?

    Why: to determine if acute or chronic.

  2. What exactly do you mean by heartburn?

    Why: typically heartburn is a burning discomfort behind the sternum (breastbone) that radiates to the throat, associated with acid reflux, aggravated by heavy meals, swallowing hot and cold fluids, stooping, lying flat and lifting and straining, more likely to occur at rest than with exertion. Heartburn may be due to gastro-esophageal reflux, oesophagitis, hiatus hernia, peptic ulcer, scleroderma, pregnancy, obesity, smoking and alcohol, caffeine and some medications.

  3. Is there anything that makes the heartburn worse?

    Why: can help distinguish gastro-esophageal reflux (heartburn) from other causes of abdominal discomfort e.g. eating food may aggravate a gastric ulcer; eating fried or fatty foods will aggravate biliary disease, esophageal disorders and functional dyspepsia ( dyspepsia when no specific cause can be demonstrated); bending over will aggravate gastro-esophageal reflux; alcohol will aggravate gastro-esophageal reflux, oesophagitis, gastritis, peptic ulcer and pancreatitis.

  4. Is there anything you have found that makes the discomfort better?

    Why: Gastro-esophageal reflux is usually relieved by antacids within several minutes.

  5. What effect do food, milk and antacids have?

    Why: if discomfort is relieved by food and antacids may suggest duodenal ulcer, hiatus hernia and oesophagitis. If discomfort is brought on by food may suggest cholecystitis, gastric ulcer or reactions to toxins in food such as MSG or sulfites.

  6. What effect do coffee, onions and garlic have?

    Why: aggravate gastro-esophageal reflux.

  7. What effect does a big meal have?

    Why: aggravate gastro-esophageal reflux.

  8. What effect does drinking alcohol have?

    Why: aggravate gastro-esophageal reflux, gastritis and peptic ulcers.

  9. What effect does exercise have?

    Why: chest discomfort precipitated by exercise may suggest angina as cause of discomfort if brought on by exertion. Exercise may also precipitate heartburn.

  10. Do fried or fatty foods make it worse?

    Why: aggravate gallstones.

  11. Do hot spicy foods effect it?

    Why: aggravate gastro-esophageal reflux, gastritis and peptic ulcers.

  12. Does the problem come on at night soon after you go to bed?

    Why: would suggest gastro-esophageal reflux.

  13. Does it wake you at night?

    Why: may suggest gastro-esophageal reflux or peptic ulcer.

  14. Does bending over such as in gardening make it worse?

    Why: suggests gastro-esophageal reflux.

  15. Are you under a lot of stress or have a lot of worry?

    Why: may aggravate indigestion due to affecting motility and suggests gastro-esophageal reflux, peptic ulcers.

  16. Do you rush your meals?

    Why: may aggravate indigestion.

  17. Do you chew your food properly?- if not, may aggravate indigestion
  18. Are you pregnant?

    Why: pregnancy increases the risk of gastoesophageal reflux due to a relaxation of the lower esophageal sphincter.

  19. Past medical history?

    Why: e.g. scleroderma (rare but important cause of oesophagitis), irritable bowel syndrome, gallstones, chronic pancreatitis, achalasia, hiatus hernia, pernicious anemia (may increase the risk of stomach cancer).

  20. Medications?

    Why: e.g. non-steroidal anti-inflammatory medications (2-4 times the risk of gastric ulcers), anticholinergics, aspirin, calcium channel blockers, corticosteroids, digitalis, lipid lowering medications, narcotics, slow release potassium supplements, theophylline, tricyclic antidepressants and tetracycline - may all cause gastro-esophageal reflux.

  21. Nicotine smoking?

    Why: cigarette smoking is an important cause of reducing the pressure of the lower esophageal pressure and thus increasing the risk of gastro-esophageal reflux. Smoking also increases the risk of peptic ulcers.

  22. Alcohol history?

    Why: alcohol is an important cause of reducing the pressure of the lower esophageal pressure and thus increasing the risk of gastro-esophageal reflux. Alcohol may also increase the risk of peptic ulcers.

  23. Frequent acid regurgitation?

    Why: suggests gastro-esophageal reflux, hiatus hernia, gastritis or previous gastrectomy (surgical removal of stomach).

  24. Waterbrash (excess secretion of saliva into the mouth)?

    Why: may suggest gastro-esophageal reflux, hiatus hernia or peptic ulcer.

  25. Recurrent nausea and vomiting?

    Why: most likely diagnosis is gallstones, cholecystitis or chronic pancreatitis.

  26. Vomiting of blood or recurrent back tarry stools (melena)?

    Why: should suggests peptic ulcer.

  27. Pain on swallowing?

    Why: may suggest oesophagitis (especially if with hot and cold fluids) or stomach cancer.

  28. Cough or wheeze at night? -may suggest gastro-esophageal reflux
  29. Symptoms of angina or heart attack?

    Why: e.g. -a common mistake is to attribute the discomfort of angina or a heart attack to a disorder of the gastro-intestinal tract. Must consider heartburn symptoms to be ischemic heart disease until proved otherwise.

  30. Recent weight loss?

    Why: if associated with upper abdominal discomfort and indigestion may suggest stomach cancer, intestinal or mesenteric ischemia, pernicious anemia, chronic pancreatitis, chronic gastritis. Should also consider renal failure, cirrhosis of the liver and congestive heart failure.

  31. Symptoms of peptic ulcer?

    Why: e.g. intermittent symptoms of gnawing or burning-type pain in the epigastrium (midline, under the ribs) which can be located by finger point, pain is worse before meals and relieved by taking antacids or food. Pain may waken the person at night.

  32. Symptoms of chronic pancreatitis?

    Why: e.g. deep boring upper abdominal pain, often radiating through to the back, fatty stools that float in toilet and are difficult to flush, possibly symptoms of diabetes.

  33. Symptoms of gallstones?

    Why: e.g. sudden onset of severe constant epigastric pain which may pass into the back. Symptoms are induced by a fatty meal.

  34. Symptoms of anemia?

    Why: e.g. tiredness, dizziness, muscle weakness, headache, shortness of breath on exertion - may suggest chronic oesophagitis, chronic gastritis, peptic ulcer or stomach cancer.

Conditions listing medical symptoms: Heartburn:

The following list of conditions have 'Heartburn' or similar listed as a symptom in our database. This computer-generated list may be inaccurate or incomplete. Always seek prompt professional medical advice about the cause of any symptom.

Select from the following alphabetical view of conditions which include a symptom of Heartburn or choose View All.

View All A B C D E F G H I J L M N O P R S V W X Z

Conditions listing medical complications: Heartburn:

The following list of medical conditions have 'Heartburn' or similar listed as a medical complication in our database.

 

By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise