Heart Failure Questionnaire

If you have been advised by the surgery to submit heart failure questionnaire, please use this form. If your symptoms are deteriorating or you are having any concerns, please make an appointment with our Nurse.

Further Information:

Heart Failure Questionnaire

Have you received a letter, text message or verbal invitation to complete this assessment?

Have you had any overnight hospital admissions relating to your heart in the past 12 months? *
We would like to know about your level of breathlessness: *
Has this changed since your last review? *
Are you able to exercise? *
Has this changed since your last review?
Do you smoke or vape? *

Blood Pressure

Please visit practice to use monitor in our waiting room if you do not have access to home BP monitor
Please use this date format: DD/MM/YYYY.
/

Height unit:
Weight unit:
Do you drink alcohol? *

How often do you drink alcohol? *

E.g. Monday AM/PM, Tuesday AM/PM
*