Heart failure questionnaire

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

Yes

No

Have you had any overnight hospital admissions relating to your heart in the past 12 months? *

Yes

No

In which months were you admitted to hospital?

We would like to know about your level of breathlessness: *

I only get breathless with strenuous exercise

I get breathless when hurrying on level ground or up a slight hill

I walk slower than people my age when walking on level ground because of breathlessness or have to stop to catch my breath when walking on level ground

I stop for breath after walking 100 yards or every few minutes

I am too breathless too leave the house most of the time

Has this changed since your last review? *

Yes

No

Are you able to exercise? *

Yes

No

What limits your exercise?

What exercise do you do?

Has this changed since your last review?

Yes

No

Do you smoke or vape? *

Yes

No

What do you smoke?

How much do you smoke or vape?

How long have you smoked or vaped?

Blood Pressure

Please visit practice to use monitor in our waiting room if you do not have access to home BP monitor

Date: *

Please use this date format: DD/MM/YYYY.

Systolic “Higher” *

/

Diastolic “Lower” *

Heart Rate *

Height:

Height unit:

Inches

CM

Weight:

Weight unit:

Stone

KG

Do you drink alcohol? *

Yes

No

How often do you drink alcohol? *

Daily

Every few days

Weekly

Monthly

What is your drink of choice?

How many of these drinks will you have each day?

If we need to contact you to discuss anything related to your form when is the best time to contact you? *

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

*

I confirm that the information provided is accurate to the best of my knowledge

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Blood Pressure