Heart Failure Annual Review Heart Failure Annual Review Please complete the online form below to submit your Heart Failure Annual Review First Names Surname Date of Birth Day Month Year Contact NumberEmail Address Enter Email Confirm Email Please ensure the questionnaire is completed in full.1. Which describes your symptoms best? I can perform all physical activity without getting symptoms I get symptoms when performing more strenuous activities e.g., walking on steep inclines or walking up several flights of steps I get symptoms when performing day to day activities e.g., walking on flat ground I get symptoms at rest and am mostly housebound. I am unable to carry out any physical activity without getting symptoms The most common symptoms of heart failure are breathlessness, tiredness, and palpitations.2. Exercise Tolerance Good. No limitations. I can manage more than 1 mile Fair. I can manage up to half a mile on flat ground. Walking up inclines causes shortness of breath Moderate. I am limited to 100 yards at best. Washing and dressing causes shortness of breath Poor. I’m short of breath at rest 3. Fatigue None After moderate physical effort (e.g., walking down the corridor or showering) After mild exertion (e.g., washing and dressing) After minimal exertion (e.g., standing from the chair, walking slowly) At rest Feeling unusually tired and weak.4. Do you have any oedema? None Mild (resolves after rest) Moderate (e.g., mid-calf / below knee) Above knee Thigh / Abdomen This is excess water causing swelling in the tissues. It most commonly affects the feet and the ankles but can also occur higher up on the leg or in the abdomen.5. Do you suffer from sudden wakening at night due to shortness of breath? Yes No 6. How much fluid do you drink each day? <1 litre 1 – 1.5 litres 1.5 – 2 litres >2 litres 7. Pulse Rate Check (Optional) Optional You can check your heart rate at rest by taking your pulse and counting how many times you heart beats in a minute. Your pulse will also be shown on most blood pressure machines.8. During the last month have you often been feeling down, depressed, or hopeless? Yes No 9. During the last month have you often been bothered by having little or no interest or pleasure in doing things? Yes No 10. Your current weight? Optional Please enter your current weight and the unit of measurement used (Stones and Pounds, Pounds only, Kilograms)Blood Pressure Readings (7 Days am/pm)Day 1 Systolic (AM)Day 1 Diastolic (AM)Day 1 Systolic (PM)Day 1 Diastolic (PM)Day 2 Systolic (AM)Day 2 Diastolic (AM)Day 2 Systolic (PM)Day 2 Diastolic (PM)Day 3 Systolic (AM)Day 3 Diastolic (AM)Day 3 Systolic (PM)Day 3 Diastolic (PM)Day 4 Systolic (AM)Day 4 Diastolic (AM)Day 4 Systolic (PM)Day 4 Diastolic (PM)Day 5 Systolic (AM)Day 5 Diastolic (AM)Day 5 Systolic (PM)Day 5 Diastolic (PM)Day 6 Systolic (AM)Day 6 Diastolic (AM)Day 6 Systolic (PM)Day 6 Diastolic (PM)Day 7 Systolic (AM)Day 7 Diastolic (AM)Day 7 Systolic (PM)Day 7 Diastolic (PM)
