Heart Failure Annual Review

Heart Failure Annual Review

Please complete the online form below to submit your Heart Failure Annual Review

Date of Birth
Email Address

Please ensure the questionnaire is completed in full.

1. Which describes your symptoms best?
The most common symptoms of heart failure are breathlessness, tiredness, and palpitations.
2. Exercise Tolerance
3. Fatigue
Feeling unusually tired and weak.
4. Do you have any oedema?
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?
6. How much fluid do you drink each day?
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?
9. During the last month have you often been bothered by having little or no interest or pleasure in doing things?
Please enter your current weight and the unit of measurement used (Stones and Pounds, Pounds only, Kilograms)

Blood Pressure Readings (7 Days am/pm)